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METHODS AND PRINCIPLES 

OF TEACHING THE PRINCIPLES AND 

PRACTICE OF NURSING 



THE MACMILLAN COMPANY 

NEW YORK • BOSTON • CHICAGO • DALLAS 
ATLANTA • SAN FRANCISCO 

MACMILLAN AND CO., Limited 

IjONDON • BOMBAY • CALCUTTA • MADRAS 
MELBOURNE 

THE MACMILLAN COMPANY 
OF CANADA. Luutbd 

TORONTO 



Methods and Principles 

of Teaching the Principles and 

Practice of Nursing 



BY 

BERTHA HARMER 

B.Sc. (Columbia University), R.N. 

ASSISTANT PROFESSOR YALE UNIVERSITY SCHOOL OP NURSING; 

FIRST ASSISTANT SUPERINTENDENT OF NURSES, THE 

NEW HAVEN HOSPITAL, NEW HAVEN, CONNECTICUT. 



THE MACMILLAN COMPANY 

1938 



6 16.73 



Copyright, 1926, 
By the MACMILLAN COMPANY. 



Set up and printed. 
Published May, 1926. 

All rights reserved — no part of this book may be reproduced ia 

any form without permission in writing 

from the publisher. 



PRINTED IN THE UNITED STATES O? AMERICA BY 
THE FERRIS PRINTING COMPANY 



PREFACE 

The application of the methods and principles of teaching, to 
the teaching of the course in the Principles and Practice of Nurs- 
ing constitutes the subject matter of this brief work, written in 
response to a growing demand for a book designed especially 
for teachers in schools of nursing. It is written, also, in recog- 
nition of the fundamental importance and inclusiveness of the 
subject, itself; and the great and unique opportunity in educa- 
tion that the course in nursing offers, to use and apply those 
principles and methods based upon the laws of learning. 

This opportunity arises chiefly through the necessity of teach- 
ing and learning by practical experience in the natural setting 
of the wards and out-patient department clinics. Particular 
emphasis is, therefore, given to this phase of the course. 

The text is divided into three main sections: The first presents 
the aims and content of the course, its method of selection and 
organization into topics, its proper sequence with special em- 
phasis upon the importance and method of correlating theory and 
practice. 

The second section presents methods of teaching. The applica- 
tion of the laws of learning is developed by the use of many 
practical suggestions and illustrations, by numerous projects out- 
lined and others fully described. An example of a method of 
teaching a lesson in practical nursing, together with a suggestive 
thought-provoking outline of a nursing procedure, is given. 

The third section deals with teaching and learning through 
practical experience. The content of this phase of the course, its 
selection and organization into topics, its sequence, correlation of 
theory and practice, the methods of planning the experience and 
assigning patients, methods of teaching, the use of projects, case 
studies, experience records, and a scientific method of work and 
study are all discussed. 



vi PREFACE 

Illustrations of methods in the form of tables, outlines, and 
forms or records are used throughout. These forms are being 
used in an experimental way at the Yale University School of 
Nursing. They should be regarded as an effort to work out 
certain principles, and not, in any sense, as established or per- 
fected forms or methods. They will be revised as further experi- 
ence in their use and development may indicate. References for 
further study are also included. 

It is hoped that the text will be of interest to all who are con- 
cerned with nursing and of use to superintendents, instructors, 
supervisors and headnurses, and to all who are concerned with 
the vital problem of what to teach and how to teach this course 
in nursing — ^the heart of our curriculum, the course for which 
all the others exist. 

It is the author's earnest wish that the publication of this text 
will stimulate further discussions and developments in the teach- 
ing of this all-important subject. 

The writer wishes to express her appreciation and gratitude to 
Miss Isabel Stewart for her critical review of the manuscript, 
and to Dean Goodrich, and Miss Effie J. Taylor for their personal 
interest in reading the manuscript. 

Thanks are also gratefully given to those teachers, instructors, 
supervisors and headnurses — ^who have so ably, so enthusiasti- 
cally, and so patiently helped to develop these principles and 
methods of teaching and learning through the practical experi- 
ence. 



CONTENTS 

PAGE 

L Aims of the Course 1 

What Purpose and Importance Have Aims? What 
Determines Our Aims? What Is Our Basis of Selection? 
Summary of Teacher's Aims Selected. 



11. Content of the Course of Study 



Job Analysis of Duties, Difficulties and Problems; Sub- 
ject Matter Organized Under Topics; Analysis of Ethical 
or Professional Ideals, Attitudes, and Appreciations; 
Analysis of Standards of Work; References. 

III. Methods of Teaching 33 

What Is Teaching? Preparation of the Teacher; Class- 
room Teaching; Method of Teaching Based on Laws of 
Learning; Laws of Learning — Law of Readiness; Law of 
Effect; Law of Exercisej Practice Preceded by Teacher 
Demonstration; Amount of Practice Based on Need and 
Individual Achievement; Law of Association — Teaching 
Principles; Teaching Skill (Form or Style and Execu- 
tion); Teaching Standards; Teaching to Think; Teach- 
ing Qualities of Heart and Mind; Project Method in 
Teaching and Learning — The Producer's Project, the 
Consumer's Project, the Problem Project, the Drill Proj- 
ect; Developing the Project; Teaching a Lesson in the 
Principles and Practice of Nursing — The Teacher's Prep- 
aration of the Lesson; The Method of Presenting the 
Lesson; The Demonstration; Student's Practice in Class- 
room; The Assignment; Review Demonstration; Use of 
Examinations; Use of Text and Reference Books; 
References. 

IV. Teaching and Learning by Personal Experience 

IN the Wards, Out-patient Department, and 
Community 80 

Content of the Course of Study; Subject Matter Organ- 
ized Under Topics; Job Analysis of Standards of Work, 
Attitudes, and Appreciations; Content of the Course 
vU 



viii' CONTENTS 

SECTION PAGB 

Indicated as Inside the Ward; Sequence of Topics or 
Services and Time Required in Each; Services Included 
in Experience. 

V. Methods of Teaching in Wards and Clinics . 95 

Methods Based on Laws of Learning — Mind-set or Pur- 
pose — Service to Patients; Mind-set or Purpose — Spirit, 
Ideals and Method of Science; Service to Patient as an 
Individual the Centre of Thought; Methods of Assign- 
ing Patients — Efficiency Method or the Patient the 
Centre of Thought; Advantages and Disadvantages of 
Methods; Use of Assignments and a Scientific Method 
of Study in the Wards; Study of Patient's Needs to 
Precede Nursing Care; Treatment Cards; Case Studies 
and Experience Records — Principles and Method of 
Using; Conferences; Case Study References; Case Study 
Committee; Written Instructions; Outline of Routine 
Nursing Care; Evaluation of Experience; Method of 
Keeping Records; Method of Grading; Value of the 
Written Word; References. 



LIST OF FORMS, TABLES AND OUTLINES 

PAGE 

Tables I and II — Individual Procedure Cards . . 8 and 16 
Outline of Course in the Principles and Practice of Nursing 24 

Program of a Review Demonstration Conducted as a 

Project 50 

Outline of a Method of Procedure in Nursing .... 68 

Instructor's Outline of Special Procedures to be Taught 

in Communicable Diseases 84 

Instructor's Outline of Special Procedures to be Taught 

in Pediatrics 86 

Clinical Experience — ^Assignment of Patients .... 104 

Treatment Card Attached to Chart 115 

Outline of Case Study 117 

Outline of Experience Record and Summary . 126 and 133 

Outline of Routine Nursing Care in a Medical and Surgi- 
cal Ward 129 



METHODS AND PRINCIPLES 

OF TEACHING THE PRINCIPLES AND 

PRACTICE OF NURSING 

SECTION I 
AIMS OF THE COURSE 

What Purpose and Importance Have Aims? — Aims deter- 
mine our ideals, our mental attitudes, our standards of work, 
our attitude toward, and our relations with the patients, the 
students, and others. They also control, direct, or guide in the 
selection and development of the content of the course, and the 
means or methods of teaching both in theory and in practical 
experience. 

To serve their best purpose, aims should not be fixed or final, 
because conditions change and aims must be expanded, extended, 
or altered to meet new needs or to emphasize the correction of 
particular weaknesses or defects in the school or profession at 
large. 

What Determines Our Aims? What Is Our Basis of Selec- 
tion? — 1. The Purpose of the School. Having selected prop- 
erly qualified students, the purpose of any undergraduate school 
of nursing will be to give a basic course in nursing which will 
develop the character and capacity of the individual student, 
and give a sound foundation, in knowledge, skill, and methods 
of work, for future growth and development in active service in 
the various fields of nursing. 2. The Relation of the Course in 
Nursing to Other Courses in the Curriculum and to the Various 
Fields for which students are being prepared. Nursing is the 
heart of the whole curriculum, the object for which all the rest 
is being given. So, just as a glass prism draws to it and focuses 
rays of light, so will an instructor in the Principles and Practice 

1 



2 METHODS AND PRINCIPLES OF TEACHING 

of Nursing consciously draw upon (and direct and aid the stu- 
dents in doing likewise) all the other subjects taught in the 
curriculum as a background of information, of principles, and 
of scientific methods of study and work. Again, just as the 
glass prism breaks up and redirects or refracts intensified rays 
of light previously focused, so should the course in nursing lead 
onward, redirecting and adapting knowledge and methods, etc., 
to needs wherever they may be met, whether in the hospital, 
out-patient department, or the community at large. For in- 
stance, if we believe in the claim that the scientific method of 
work used in the science laboratories, and by doctors in making 
a diagnosis, is the road to progress in knowledge, skill, and men- 
tal development (intellectual capacity) ; and that, by its use and 
application, more progress has been made in the last seventy 
years (according to an estimate made) than in the preceding 
two thousand, then we will use that method in planning the 
nursing care of patients: we will also give our students practice 
in using it, pointing out its adaptability to study and work in 
the hospital or in the community. (For application see page 
56.) Likewise, if we believe the hospital to be merely a link 
in the community health program, then, in studying, with our 
students, the needs and in planning the care of a patient in the 
hospital, our horizon will not be limited by the walls of the ward 
or hospital but will embrace all those factors, family, industrial, 
and social, which have contributed to his illness or will con- 
tribute to his future welfare. 3. The Habits of Thinking, Feeling, 
and Doing (shown in ideals, mental attitudes, appreciations, 
knowledge, and skills) which we feel are desirable and necessary. 
For instance, if we believe that the ideal of service, and of altru- 
istic purposeful endeavor, together with such qualities as fair- 
mindedness, initiative, good judgment, and reliability are desir- 
able, then we must give material and methods, and provide 
situations and environment which will develop them. 4. A Study 
and Analysis of our Resources and Difficulties, our Weaknesses 
and Defects which need to be strengthened or altered. For in- 
stance, if we believe, as educators tell us, that we learn by doing; 



PRINCIPLES AND PRACTICE OF NURSING 3 

but have found, as educators also tell us, that experience, while 
a wise teacher, may be unnecessarily hard, and our progress slow 
and uncertain, unless our experience is made intelligent, directed 
and controlled by principles and proper methods of work; then 
we will include those principles and methods in our course of 
study in the classroom and wards. 

Summary of Teachers' Aims Selected. — 1. To render the 
best possible service to the patient, the family, and the commu- 
nity. 2. To insure sympathetic, intelligent, and skilled nursing 
care of patients, and a sound, basic education for student nurses, 
believing, as we do, that the one insures and is inseparable from 
the other. 3. To help the students to help themselves by such 
methods as the following: a, by explaining to them (as women 
who are expected and who intend to learn for themselves) the 
curriculum, the purpose and problems of the school ; h, by teach- 
ing students the underlying principles and giving practice in 
recognizing and applying them to many varied problems or pro- 
cedures; c, by teaching and giving them practice in using a 
method or technique of study and work (as well as a technique 
or skill in procedures) which may be used in any piece of scien- 
tific work, whether it be in a science laboratory, a hospital ward, 
in a social agency, or in any community health activity; d, by 
developing and fostering the student mind, the attitude of the 
research worker, and the attitude of a public health and social 
service worker. This may be accomplished by having students 
share with headnurses and instructors in building up a prescribed 
program of nursing care (including preventive measures) for 
each patient, based on a study not only of the present diseased 
condition but on the patient as a whole, a human being, a mem- 
ber of a family and of the community; e, by developing in stu- 
dents thoughtfulness, initiative, resourcefulness, a constructively 
critical attitude toward their own work, and a personal respon- 
sibility for the welfare and care of their patients; and also for 
the advancement, not only of their own knowledge and skill, 
but of the general content and methods of nursing education. 

Students can't help themselves and will make little progress 



4 METHODS AND PRINCIPLES OF TEACHING 

in learning unless the environment and the situations which we 
create around them provide the opportunity, the stimulus, en- 
couragement, and practice in meeting and solving problems by 
their own thinking, their own initiative, and their own respon- 
sibility as far as the patient's and their own welfare will permit. 



SECTION II 
CONTENT OF THE COURSE OF STUDY 

The content of a course in the Principles and Practice of 
Nursing will necessarily include those ideals, attitudes, appre- 
ciations, knowledge, and skills to be taught in the classroom and 
that same content, made richer, broader, more vital and lasting 
by its natural setting, which can be learned only by personal 
experience in the wards, out-patient department, and the com- 
munity. 

The course to be given in the classroom and wards should 
be considered, not as separate subjects, but as one organic, inter- 
related whole, each supplementing and incomplete without the 
other. Indeed, it is important for us to remember, in this period 
of rapid change and expansion, that, according to modern thought 
in education, the strength of our whole educational system and 
our greatest and almost unique opportunity lie in the field of 
our practical experience. This is so because we have, in the 
situations presented in our wards, etc., those factors in educa- 
tion most truly vital and, perhaps, only essential; that is, the 
opportunity, nay, even more, the unavoidable necessity of learn- 
ing (more or less) while doing. 

Dewey says: "There is no such thing as genuine knowledge 
and fruitful understanding except as the offspring of doing," and 
that what is needed is "a reorganization of education so that 
learning takes place in connection with the intelligent carrying 
forward of purposeful activities." 

Now, rendering nursing service to a patient, whether it be in 
the wards, clinics, or community, should surely be just that — 
the intelligent carrying forward of purposeful activities; not 
just intelligent and purposeful on our part, the teachers, but on 
the part of the students who are serving and learning; and our 

5 



6 ;methods and principles of teaching 

classrooms (in contrast to the more or less artificial conditions 
and situations, remote from the problems of daily life, frequently- 
met in the classrooms of other schools) are, or should be, the 
direct outgrowth of the needs or difficulties and problems met 
in the wards ; and were merely brought in to supplement, to sys- 
tematize and round out this practical experience by principles, 
methods of work and study, and the experience of others; to 
unite the content of knowledge into a proper whole, and to make 
the teaching uniform for the whole group. The vital part of 
the course, where the students really learn the principles and 
practice of nursing, is in the wards and clinics in the actual care 
of patients. 

To meet the needs of the patients and the educational needs 
of the students are, therefore, not separate problems but one and 
the same — we cannot accomplish the one adequately without the 
other. That is, if a patient under the care of a student is not 
receiving good nursing care, then that student is not learning 
to be a good nurse; if the patient is receiving good care, then to 
this extent the student is learning good nursing. 

This emphasis on teaching and learning by doing — ^the intelli- 
gent carrying forward of purposeful activities in the natural set- 
ting of the wards — is the rock on which we should build our 
course. To place the emphasis merely or largely on classroom 
teaching and ignore this unique opportunity (as in having a 
highly qualified instructor and an elaborate course in the class- 
room and no one with time to teach or a plan for teaching in 
the wards) would be to sell our birthright for a mess of pottage. 

The content of the course may, therefore, be determined by a 
job analysis of: 1. The duties, difficulties, and problems which 
the students will meet in their practical experience both immedi- 
ate (in the wards, etc.), and remote (in the community) ; 2. The 
insight, knowledge, and understanding, and the ability to use 
the facts, underlying principles, methods of work and study 
which make experience intelligent and fruitful; 3. The habits 
of thought, jeeling, and conduct — the standards, attitudes, and 
appreciations — ^which develop character and insure present and 



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PRINCIPLES AND PRACTICE OF NURSING 13 

future happiness and success for our students and, through them, 
for our patients and for humanity. 

A Job Analysis of Duties, Difficulties, and Problems will 
include the following: 1. To adjust to the conditions of the 
classroom and to other members of the class forming a social 
group; 2. To adjust to and learn how to study and to use the 
various facilities for study; 3. To adjust to the new situations 
and complex conditions met in a large institution having many 
departments, a large and varied personnel serving a variety 
of purposes but having, however, a single objective — service to 
the patients and the community in the prevention and cure of 
disease; 4. To adjust to and share in service and responsibility 
in all matters relating to patients, each of whom presents an 
individual problem, social or family, mental and physical, 
medical and nursing; 5. To co-operate with all engaged in this 
service — ^members of the medical school, school of nursing^ 
administrative staff, and other departments such as dietary. 
X-ray, social service, laundry, etc.; 6. To carry out the various 
duties and procedures listed on Tables I and II; 7. To acquire 
knowledge of the ideas, facts, and principles which will explain 
the reason why and give content, meaning, and intelligent direc- 
tion and control of the above procedures, thus broadening their 
use and application to many varied situations; 8. To adjust 
to situations such as night duty, unexpected demands and emer- 
gencies, and to the mental and physical strain of combined 
theory and practice; 9. To keep and understand accurate, con- 
cise, statistical records such as charts, case studies, experience 
records, etc; 10. To teach patients, friends, or relatives such 
procedures as making feedings for the baby, bathing the baby, 
and preparing special diets such as diabetic diet, etc. 

Simple Job Analysis of Procedures. — Each procedure, duty, 
or problem should likewise be analyzed into elements or steps 
which, like a good recipe, give directions simple and clear enough 
to be readily grasped and carried out by the students. For 
various reasons such an analysis cannot be given here. The 
scope of the pamphlet will not permit, the conditions vary in 



14 METHODS AND PRINCIPLES OF TEACHING 

each hospital, and (while standardized methods of procedure are 
desired by many) every hospital has its own technique which 
seems to it best fitted for its own needs. In addition there 
are several books outlining the technique of procedures available. 
(See outline of procedure on page 68.) 

Subject Matter Organized Under Topics. — Having made 
the above analysis and collected the necessary facts, principles, 
and methods, it will be found very helpful to organize this 
subject matter into major topics (with their divisions and sub- 
divisions) which indicate for ourselves and our students our main 
objectives. Such topics define and give a general survey of the 
course in proper perspective. They guide and direct the students 
in their aims and plan of work and study, organizing and 
systematizing their knowledge, showing facts in their true 
relationships and giving them better control over what they are 
learning. 

These major and minor topics, in a course in the Principles 
and Practice of Nursing, would, of course, include both theory 
and practical experience as shown in the following outline. In 
such a limited study, no attempt can be made to give the sub- 
divisions of topics or outline of lessons. Some suggestions for 
such an outline may be found in the Revised Standard Curricu- 
lum prepared by the Education Committee of the National 
League of Nursing Education. In general it may be said that 
topics should be subdivided into units or lessons, the size or 
amount covered depending upon the capacity of the students 
and their ability to handle work alone. 

The form of the outline is meant to suggest the desirability of 
the close correlation of theory and practice, the theory either 
directly preceding or dovetailing with the practice as far as 
conditions will permit. This close correlation is undoubtedly 
one of our most difiicult problems; but if we set this as our goal 
and consciously strive to reach it we are much more apt to 
succeed, for we all know that where there is a will there is a 
way. 

This does not mean, as the outline seems to suggest, that a 



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19 



PRmCIPLES AND PRACTICE OF NURSING 21 

student should have all her experience in any one service at one 
time. On the contrary, it is deemed advisable by many that the 
experience be divided and the student return at a later period 
not only that she may experience it as a more mature, skilled, 
and better informed student but that she may view it from a 
different angle, with either a related or a contrasting background 
— surgical and medical, operating room and surgical ward, adult 
and child, out-patient and hospital patient, etc., — the contrasts 
and comparisons opening her eyes, making things which before 
were not visible stand out clearly and sharply. 

For this reason the outline suggests that experience in any one 
service should include the clinic in the out-patient department, 
where the emphasis is on the social and preventive side, so that 
the students may get this complete picture of the patient and of 
diseases at different stages and with different manifestations. 

The sequence suggests the desirability of having the basic or 
foundation subjects precede; for instance, of having aseptic 
technique in the operating room precede obstetrics and communi- 
cable diseases, and nursing in medical diseases of adults, and 
children (pediatrics) precede nursing in communicable diseases 
which require adaptation owing to the new and, especially with 
children, difficult factor of communicability. 

In all the above divisions of the course in the Principles and 
Practice of Nursing, it is urged that, both in theory and, es- 
pecially, in practice, the social or community aspects be em- 
phasized both from the social and public health standpoint. All 
such factors are considered because we believe that, in a com- 
munity health program, there is no sharp line, in purpose or 
function, between the hospital or out-patient department and 
the community; or between the hospital and the home, whether 
it be rich or poor; or between the hospital and any community 
activity concerned with the health needs of the individual or 
family. 

The hospital is, itself, a community activity, a necessary link 
in the whole health program; and a patient in the hospital is 
still a member of a family and the community — indeed the sick- 



22 METHODS AND PRINCIPLES OF TEACHING 

ness often accentuates the family and community relationship 
to school, industry, church or society, etc. 

From this standpoint a nurse's relation and responsibility to 
the patient is the same whether she be nursing in the hospital, 
"specialling" in the homes of the rich, doing visiting nursing in 
the homes of the poor, doing school, industrial, medical social 
service, or public health nursing. In each she is serving the 
community, doing social and public health work as a nurse and 
health teacher in the prevention and cure of disease. 

It is urged that this point of view be emphasized throughout, 
beginning with the very first lesson, because we believe that, 
unless it forms an integral part, permeating and interwoven 
with every thought, feeling, and service rendered our patients, 
it will always be external, something grafted on as an after- 
thought. If given at the end, as a separate course, the difference 
in the care and welfare of the patients would be, to use a very 
homely simile, just like adding the forgotten salt after the 
potatoes are cooked. 

This does not mean that students are supposed to be prepared, 
without postgraduate courses, for special fields in nursing; but 
that they should be taught the fundamental principles of com- 
munity nursing as an integral, organic, and functional part of 
the basic or undergraduate course in nursing. They should have 
the same broad social aims and point of view, should talk the 
same language, as it were, and, in meeting the needs of a patient 
in the hospital, should use methods of study, of observation, of 
gathering and recording data, and methods of work which would 
be applicable and useful in meeting the needs of an individual 
(taking the family as a unit) in the broader field of the com- 
munity. 

Analysis of Ideals, Standards of Work, Attitudes and 
Appreciations. — What has been said about teaching the com- 
munity aspects of nursing may be said with even greater empha- 
sis of those ideals, standards of work, attitudes of thought, of 
feeling, and our appreciations, which we all know make up the 
sum total of what we are, what we do, and the way in which 



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B. Conducted visits to 
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27 



PRINCIPLES AND PRACTICE OF NURSING 29 

we do it — in other words, our whole character and person- 
ality. 

These more or less abstract, complex terms or qualities can- 
not be taught or learned in a course of ethics; neither can they 
be left to chance. They are governed by the same laws of learn- 
ing and are acquired or learned as any skill or knowledge is 
learned, that is, by purposeful, intelligent practice in doing. 
They not only control but are inseparably interwoven with our 
daily conduct, therefore form an integral part of the content of 
our course in nursing. 

An Analysis of Ethical or Professional Ideals, Attitudes, 
and Appreciations will include the following: 1. The ideal of 
service — the desire and the will to render the most intelligent, 
unselfish, efficient, and skilled nursing service to the patient, the 
family, and the community, without regard to prejudice, nature 
or difficulties of the diagnosis, social status or personality of the 
patient, etc. 2. The ideal not only of saving life but of building 
health — ^the desire to raise the standards of healthful living by 
sharing our knowledge and skill with patients, relatives, and 
other members of the community. As a teacher of health, one 
engaged in the prevention and cure of disease, a nurse should 
maintain the highest possible standards of personal health. 
3. Lofty standards of duty — a sensitive regard for the sacredness 
of the intimate, confidential relationship between patient, fam- 
ily, and nurse and their absolute dependence upon her integrity, 
knowledge, and skill: To be such in character, reputation, knowl- 
edge, and skill as to win the respect and confidence of our pro- 
fession and the community. 4. Spirit of co-operation — the will 
to share and have others profit by our experience, to co-operate 
and co-ordinate with other members of the profession and with 
other professions in the common purpose of serving humanity. 
5. The ideal and spirit of progress — to maintain and elevate the 
quality of service and the social reputation of the profession; 
to improve our aims and methods; to increase our body of 
knowledge and skills, and to maintain and elevate the standards 



30 METHODS AND PRINCIPLES OF TEACHING 

of nursing education. 6. The ideal and spirit of science — ^the 
spirit of inquiry, of investigation, keen observation, accurate 
recording and thoughtful analysis of facts revealed, intelligent 
application with constant testing and measuring of results; a 
scientist's love of accuracy and of truth, a sensitive conscience 
in regard to personal error and one's responsibility toward the 
patient. 7. The artist's and craftsman's imagination and delight 
in creating, in doing or making something and the (Esthetic 
appreciation of good workmanship, not just in its mechanical 
aspects but for the thought and feeling expressed in it, which 
we all know are the qualities which make art fine and lasting. 
8. Self-criticism — ^The artist's critical eye, the constructively 
critical attitude which insures progress through self-testing, self- 
direction and education. 9. Such qualities as a sense of humour, 
initiative, judgment, adaptability, reliability, unselfishness, tact- 
fulness, self-control, etc., are all very desirable and necessary, 
therefore form part of the content of our course of study to be 
taught and learned. 

Analysis of Standards of Work/ — A student^s work as a 
whole as well as each procedure or service rendered to the patient 
may be measured and should be directed and controlled by the 
following standards. A student considers whether or not she is 
working with due regard to: 

1. The safety of the patient, the nurse, and others. 

2. The therapeutic effect of the treatment or service. 

3. The comfort and happiness of the patient, mental and 
physical. 

4. The economy of energy: 

a. The patient's energy — ^to what extent is it advisable? 
How far should the patient help himself? How far 
should he be helped? Should two nurses work together? 

b. The student nurse's energy as it relates to herself, her 
health, and her reserve for other patients. When should 
she request assistance in lifting, etc.? 

* Stewart, Isabel : "Possibilities of Standardization in Nursing Tech- 
nique," The Modern Hospital, June, 1919, Vol. XII, No. 6. 



PRINCIPLES AND PRACTICE OF NURSING 31 

5. The economy of time: 

a. In relation to the patient cared for: Is time of impor- 
tance to the patient? Has the time taken (in bathing 
for instance) any effect on his energy or comfort? If 
time is available could it be used to better advantage 
for the patient? 

b. In relation to the nurse, her responsibility for the com- 
fort and welfare of other patients, attendance at class 
or elsewhere, other responsibilities, and the need of 
developing habits of promptness and precision, using 
time to advantage in studying the needs of the patient 
— ^reading chart, history and laboratory reports, etc. 

6. The economy of materials: 

a. In relation to patients: Torn linen, stained linen, 
blankets, mattresses, chipped dishes or utensils, broken 
furniture, lost articles, etc., all add to the discom- 
fort of patients and sooner or later result in poor 
service. 

b. In relation to the nurse: Improper, inadequate equip- 
ment makes good nursing extremely difficult and there- 
fore difficult to develop proper ideals, standards, and 
methods. 

c. In relation to the hospital and community: The re- 
sources of the hospital and community entrusted for 
improving the conditions and the welfare of patients 
are depleted by lack of economy. 

7. Artistic, finished appearance of work: 

a. In relation to the comfort, mental and physical, of the 
patient cared for. 

b. In relation to other patients and the ward in general. 

c. In relation to the reputation of the hospital and school 
of nursing in the community. 

d. In relation to the education of the student or students. 

8. The simplicity of the procedure and its adaptability to 
new situations, such as the home, are criteria for testing 
our methods of procedure. 



32 METHODS AND PRINCIPLES OF TEACHING 

REFERENCES 

Charters, W. W. — Curriculum Construction (See bibliography 

contained) . 
KiLPATRiCK, W. H, — Source Book in the Philosophy of Educa- 

cation (See bibliography contained). 



SECTION III 
METHODS OF TEACHING 

What Is Teaching? — Teaching is the art of helping students 
to help themselves. It is based on a sympathetic understanding 
of the needs of the person taught; a spirit of comradeship, the 
ability to see difficulties and problems from the student's point 
of view, and the attitude of a fellow-student (older and more 
experienced) in meeting and solving problems with the students 
and enjoying the rewards together. 

It does not mean reading, studying, thinking, organizing mate- 
rial, planning work, being responsible for, or doing things for 
students which they can do for themselves. It means every- 
thing that we, the teachers, are — our ideals, purpose and phi- 
losophy of life, our interests, tastes, ideas, attitudes, and appre- 
ciations; and everything we do which influences the students' 
development — the atmosphere, environment, and situations which 
we help to create around them; the example we set of an alert, 
inquiring, thoughtful, well-informed mind; a mind critical but 
broad, generous in its interpretations, with the creative imagi- 
nation which sees the significance and possibilities in signs 
and symptoms observed, and in facts and situations which other- 
wise appear uninteresting, mechanical, monotonous routine. It 
means, also, seeing the possibilities in our students, directing, 
guiding, and stimulating them to their highest endeavour and 
leading them on to become purposeful, independent workers, 
capable of overcoming difficulties, recognizing and solving prob- 
lems by themselves, sharing in the responsibility of rendering 
the best possible service to their patients and by so doing con- 
tributing to their own learning and development. 



34 METHODS AND PRINCIPLES OP TEACHING 

Preparation of the Teacher. — To accomplish the above, a 
teacher would have to know her students well — their previous 
education and experience, their capacities both physical and 
mental, their interests and appreciations — aesthetic, intellectual, 
and social. She should, also, not only know her subject well 
(which includes a knowledge of both the difficulties and oppor- 
tunities of teaching in the wards and clinics, etc.) but should 
be on hand in the wards, either personally or through her assist- 
ants, to help the students solve difficulties and problems as they 
arise, in other words, when they, the teachers, are actually 
needed. Otherwise students not only forget what they are 
taught but they fail to bridge the gap between classroom 
and ward, between theory and practice, and there is danger 
of setting up conflicting standards of what is acceptable in 
the classroom and acceptable or permissible in actual practice 
or experience. 

A working knowledge of the principles and methods of teach- 
ing is highly desirable, and added experience in the various fields 
(especially in community health activities) for which the stu- 
dents are preparing will be found extremely helpful and, per- 
haps, almost essential in order to properly interpret the needs 
of the patients. 

Classroom Teaching. — To discuss the classroom in full, its 
equipment and preparation, etc., would require more space than 
the scope of this present pamphlet permits. In general, it may 
be said that the hygienic conditions, atmosphere of comfort, 
attractiveness, system, order, efficiency, the equipment and 
method of work and study should all be such as to establish 
those ideals, standards, attitudes, and habits of thought, feeling, 
and doing which we feel desirable. The class situation presented 
should be that of a social group engaged in purposeful activities 
(individually or in groups) in a natural setting; that is, a class- 
room which reproduces the ward as far as possible not only in 
equipment and methods but in student activity and responsi- 
bility, thus enabling the students to adjust most readily to the 
ward, clinic, or home. 



PRINCIPLES AND PRACTICE OF NURSING 35 

The class arrangement has much to do with successful teach- 
ing. The teacher elevated on a platform, the students seated 
with their backs to each other are not conducive to free inter- 
change of thought or discussion, or to the feeling of sharing in 
the solution of problems or in rewards common to the whole 
group. A satisfactory arrangement is to have the students 
seated (comfortably for writing) in a semi-circle or on three 
sides of a rectangular table or space so that they all see each 
other, as well as the teacher, the board, and the demonstration, 
etc. It is not necessary and is, in many respects, even undesir- 
able, that the classroom, in order to have students readily adjust, 
should be an exact reproduction of the wards. Even in the same 
hospital, wards often vary. They are often not suitable for 
classrooms in size, shape, and general arrangement, or in the 
amount and distribution of equipment, or in the size and loca- 
tion of linen rooms, utility rooms, or kitchen. When planning 
a classroom laboratory for teaching dietetics no attempt is made 
to exactly reproduce a kitchen. The purpose of the room, the 
necessity of having a number of students frequently engaged 
in the same thing at the same time, the necessary provision for 
demonstration, practice, and supervision (with ease in changing 
from one to another), and constant need for and emphasis on 
the principles of economy of time, energy, and materials are 
all factors which should receive careful consideration in plan- 
ning and equipping a classroom whether it is to be used for the 
teaching of dietetics or the principles and practice of nursing. 

While it is important that the students learn, in the classroom, 
what good nursing really is, it is, on the other hand, poor teach- 
ing, and fatal to the morale, if the equipment and methods used 
and the standards set are not such as we have a reasonable hope 
of attainment in the wards. At least a minimum standard 
should be set and maintained in the wards and the students 
constantly made to realize how, why, and to what extent it 
may fall short. For instance, we may feel it desirable and 
strive to bathe patients, change the linen more frequently, and 
give more hours per day of nursing service to each patient than 



36 METHODS AND PRINCIPLES OF TEACHING 

conditions, at present, permit. This temporary failure should 
not lower our standard, but the difficulties should be accepted 
by all as a common problem to solve. In this way, by con- 
stantly testing and striving, students learn to plan their work 
and develop good judgment, a sense of responsibility and of 
relative values in all matters concerned with the safety and 
comfort of patients, the economy of time, energy, and materials, 
and the artistic finished appearance of their work. 

This feeling of consciously striving for better standards, no 
matter how near we may seem to approach perfection, is, in 
itself, a very desirable habit to inculcate. 

Methods of Teaching Based on Laws of Learning 
We teach only in order that students may learn. Our meth- 
ods, therefore, will meet with success only in so far as they 
are in accord with the laws which govern the process of learn- 
ing. And although we may feel that conditions make it almost 
impossible to obey these laws yet the laws themselves, like all 
laws, remain true and unalterable, whereas conditions and meth- 
ods which interfere may be changed if we consciously and con- 
stantly strive in the right direction and know wherein we suc- 
ceed or fail. 

The Laws of Learning formulated by Dr. Thorndike are as 
follows: 1. The Xaw of Readiness, Mind-Set-to-an-End, or 
Purpose : When a bond is ready to act, to act gives satisfaction 
and not to act gives annoyance; when a bond is not ready to 
act, to be forced to act gives annoyance. The condition of readi- 
ness means ''the degree of stimulation needed at any given time 
to bring about a given response, the greater the readiness, the 
less stimulation is needed." Mind-set refers to one's whole men- 
tal attitude toward a particular person or thing. This set acts 
as a controlling interest and purpose which "takes possession 
of the mind" at the time and which "makes more ready all one's 
inner resources (response bonds) that by previous inner con- 
nection seem pertinent to the activity at hand." "Simulta- 
neously, this set also makes unready all those response bonds 



PRINCIPLES AND PRACTICE OF NURSING 37 

whose action might interfere with attaining the end in view." 
This_lgjK.,£iaaphasiaes the importance of having a definite, abid- 
ing, and worthwhile purpose, and one strong and earnest enough 
not to be turned aside by difficulties or annoyances in the way. 
We instinctively recognize this when we ask students to state 
why they wish to study nursing. 

This law endorses the following methods previously suggested: 
The psychological order of subject matter vs. the logical order; 
that is, lessons arranged according to the interests and needs of 
the students as difficulties, or problems, and opportunities for 
learning arise in their practical experience, instead of dividing 
the subject matter into lessons, the number and content of each 
lesson depending upon the hours devoted to the subject, and 
the sequence being merely from the simpler to the more com- 
plex duties; or based merely on any other logical arrangement 
such as all the baths, or all the enemata, or all the cold or hot 
applications regardless of whether or not such instruction relates 
to the student^s present interests, purposes, or needs. 

The practice of correlating the lessons in practical nursing 
with other subjects, such as anatomy, physiology, chemistry, 
etc., is in accord with this law. The practice of dividing the 
course into preliminary and advanced nursing, and into nurs- 
ing related to various branches such as medicine, surgery, etc., 
is in keeping with the principles of proceeding from the simpler 
to the more complex and from the known to the unknown, and 
(while capable of retaining the advantages of systematic, logical 
order) is, at the same time, psychological in arrangement, in 
that it makes the correlation of theory and practice possible. 
Within each of these divisions the order of presentation should, 
of course, be psychological. 

This does not mean that only such principles and problems 
would be discussed and only such procedures taught as actually 
arose in the ward at the time but that such actual problems or 
treatments would be the starting point, the occasion for building 
up a systematized, organized knowledge of related duties having 
a similar purpose and based on common principles. For instance, 



38 METHODS AND PRINCIPLES OF TEACHING 

a cold sponge ordered, or the presence of a patient likely to need 
a cold sponge, might be the occasion for teaching the principles 
of cold applications and other treatments based on the same 
principles. A cleansing enema, however, would not be the occa- 
sion for teaching a nutrient enema — other principles are in- 
volved, the purpose or effect desired and therefore the method 
of giving are different. It is possible that a nutrient enema 
required might be the occasion for teaching a cleansing enema 
(if not already taught) because the one is often of no effect 
without the other. 

A practice related to the above is that of teaching the indi- 
vidual student in the wards (provided she can be properly 
taught and supervised) nursing measures when their use is 
apparent; that is, giving the student complete care and respon- 
sibility for her patients — the ''case method" of assignment. An 
important principle to remember in giving any assignment — 
lesson, patient, or treatment — is that it must not be too difi&cult 
either to comprehend or to do satisfactorily. Interest, desire, 
and need may be present, but if too difficult or too early for 
principles to be understood, then the resulting discouragement 
and dissatisfaction will almost surely inhibit future interest and 
learning. For instance, in the opinion of the writer, such treat- 
ments as a catheterization or the administration of medicine, 
should not be given early in the course because of the possible 
danger to the patient and the principles, skill, accuracy, and 
precision required. Cystitis resulting from faulty technique or 
a serious result due to an error in giving medications would 
almost surely cause a conscientious student discouragement, 
remorse, and lack of self-confidence which would undoubtedly 
react unfavorably on her future learning not only in relation 
to the above procedures but to her whole experience. 

Any method which arouses interest, a plan or purpose, or 
desire to learn (such as a demonstration skilfully done, a refer- 
ence to or quotation from a book, early contact with the wards, 
encouraging observation of patients, and of skilled work done 
by older students, assigning patients in advance for the purpose 



PRINCIPLES AND PRACTICE OF NURSING 39 

of study and planning nursing care, giving long-term assign- 
ments as in dividing the course into topics and sub-topics with 
references, suggestive questions, projects and methods of study, 
etc.), is in accord with this law. 

The whole project method of teaching (discussed later) is 
based upon and is in accord with this and the following laws. 

2. The Law of Effect — the Law of Satisfaction (or Success) 
and Annoyance (or Failure) : "A modifiable bond is strength- 
ened or weakened according as satisfaction or annoyance attends 
its exercise.'^ "The fastest learning, other things being equal, 
is where both are used; satisfaction when they go right, annoy- 
ance if they go wrong." 

This means that the satisfaction which comes to students from 
seeing, hearing, reading, or doing something which fits in with, 
or helps them in what they have planned and purpose doing, 
and the satisfaction arising from the success likely to follow 
whole-hearted interest and effort not only stimulate the learn- 
ing process but are necessary to it. 

Dr. Thorndike states in this connection that the discipline 
from enduring the disagreeable seems far outweighed by disci- 
pline from working with interest along lines that fit one's 
abilities. 

This law emphasizes the importance of having definite, con- 
crete ideals and standards whereby not only the teachers may 
measure, reward, or redirect the students, but by which the 
students themselves, by self-testing, may find a personal satis- 
faction (or annoyance) and develop the qualities of self -respon- 
sibility, self-reliance, and the capacity for self-direction. These 
standards or measuring rods should not be stored away to be 
brought out on special occasions, such as examinations at stated 
intervals, but should be in constant use, a part of one's mental 
attitude, functioning actively, as it were, like one's appetite 
which tells normal individuals when they need food, what kind 
of food, when they have had enough, and whether they are 
satisfied or dissatisfied. 

The standards should be posted and itsed constantly in the 



40 METHODS AND PRINCIPLES OF TEACHING 

classroom to measure and weigh each step in a procedure, each 
principle and attitude, etc. The same standards should like- 
wise be posted and used in the wards and clinics. 

3. The Law of Exercise (Repetition) or Use and Disuse 
states ''that within limits the more often a response is made to 
a situation the closer becomes the bond connecting the two; 
that is, the more surely and smoothly is the response made when 
the situation presents itself." 

"Within limits" means that there are other determining fac- 
tors in the learning process besides the number of repetitions. 
The first is the intensity of the exercise or experience — ^the 
degree of interest, of surprise or variety, and absence of monot- 
onous routine, the significance or worthwhileness of the exercise 
or experience, and the setting or the time, place, and conditions 
under which performed. 

A second important factor is recency or interval in time and 
space between the practice, repetition, or experience. This deter- 
mines whether the association or habit will be ''fixed," in other 
words learned, or not. A very important factor in the formation 
of habits is the Law of Effect; the practice or repetition must 
be accompanied by conscious improvement, merited reward, and 
satisfaction. If the need for practice or repetition is not felt, 
or if (because of lack of appreciation or of proper direction and 
guidance) the repetition brings no conscious improvement or 
reward; or if carried on with fatigue, discouragement, or dis- 
satisfaction, the habit formed will be one of dislike and avoid- 
ance — the mind becomes "set" against it with resulting failure 
to learn anything by it. 

It is evident then that this law with its modifying factors, 
needs very careful consideration and application in teaching and 
learning when skill is one of our main objectives. Moreover it 
applies equally to the formation of habits of keen, discriminat- 
ing observation; to habits of thinking (reasoning, analyzing, 
organizing, planning, applying principles, using imagination, ini- 
tiative, and good judgment in solving problems independently 
or in groups) ; and to habits of feeling (attitudes, appreciations, 



PRINCIPLES AND PRACTICE OF NURSING 41 

standards, qualities of heart and mind). It is these standards 
and qualities which should make the students, by their own 
self- testing, feel the need of practice; and such measurements 
determine when drill is needed, how much is needed by the 
individual student and the group, how much should be practiced 
in class periods or in free time, and whether in the classroom or 
in the wards. 

Practice Preceded by Teacher Demonstration.' — In addi 
tion to the feeling of need, of readiness and mind-set, the stu- 
dents, before practising, should have a clear aim, definite direc- 
tions, and an accurate understanding of what it is they are 
trying to attain. Accuracy, both of the idea or principle in- 
volved, and of execution, is very necessary. For this reason a 
demonstration complete from start to finish should always be 
given by the teacher so that the students may have a clear 
image of the whole process before attempting to practise it. 
Otherwise they form inaccurate ideas and bad habits. The 
demonstration may be repeated if the students desire it, first 
having them state which steps they particularly wish empha- 
sized. The first practice by the students, because of the law of 
recency, should immediately follow the demonstration. Dur- 
ing practice, emphasis (law of intensity) should be placed on 
the more difiicult parts, practising them the greater part of the 
time. For instance, in learning to make beds, students should 
not "just practise beds for an hour," as they say, but, having 
made a bed, should turn a critical eye over the whole process 
and the finished product so as to know just what they hope 
to improve and how to go about it, in making the next bed. 

Amount of Practice Based on Need and Individual Achieve- 
ment. — As stated previously, this will be determined by stand- 
ard measurements and the felt need for practice. It is here, 
as well as in regard to study, that work on an individualized 
basis becomes desirable and necessary — some students will have 
to study or practice much more than others to reach the same 
standard or level of achievement. It is advisable that class- 
room time be used until the students have the right idea and 



42 METHODS AND PRINCIPLES OF TEACHING 

method. Then they may be expected to practise in their free 
time individually or in small groups organized on a basis of 
ability. A minimum amount of practice (in terms of number 
of beds, etc.) may be set for all, otherwise the amount being 
determined by their level of achievement. A natural setting for 
practice, that is, a real purpose, is always desirable. The needs 
in the wards, for instance, give ample opportunity to all for 
practising beds, and the students have the satisfaction (with all 
its fruitful results in learning) of doing something worthwhile 
and useful to others. At the same time, by observation, by 
contact with others and the needs of the patients they are 
developing a mind-set-to-an-end. All such treatments, or steps 
common to a variety of treatments, which we know will have 
ample use and practice in the wards, need less practice in the 
classroom insuring, of course, that students have the correct 
idea and method and can have adequate assistance or super- 
vision. 

Such treatments as cupping or bladder irrigations, while they 
form part of the course, may be used infrequently in the wards. 
More time will need to be given them in the classroom, part of 
the function of the classroom being to round out the experience, 
which varies in amount and variety, in the wards. The occasion 
for teaching may be the need felt in the experience of, perhaps, 
only one student but the opportunity should, if possible, be ex- 
tended to all. Again, we cannot always be guided by what is 
used in any one hospital. For instance, mustard pastes and 
flaxseed poultices are not used at all in one hospital known to 
the writer, but are used in many others, as well as in the com- 
munity, so it would not seem fair to allov/ students from any 
hospital to graduate without knowing how to make and apply 
pastes and poultices. 

The amount of time spent in practice in the classroom is 
often, in the opinion of the writer, out of proportion to the needs 
of the students and the difficulty of the procedure. For instance, 
much time is often spent in practicing making beds while a 
limited time is spent in such measures as draping patients for 



PRINCIPLES AND PRACTICE OF NURSING 43 

various examinations; although the latter is difficult, not only 
because of the personal element of patient and doctor, the 
variety of positions and methods, the promptness and skill 
required, the uncertainty as to just what is likely to be required, 
but because the particular draping may be required only infre- 
quently. The habit has not time to be ^'fixed" and we get 
"out of practice" when the intervals between instruction, use, 
or practice are prolonged. Until habits are firmly estab- 
lished the intervals at first should be short, then gradually 
lengthened. 

The law of intensity is an important factor in fixing or in re- 
membering, which partly explains why things taught and learned 
in the wards, where the happiness and lives of human beings are 
at stake, make such a lasting impression. It is not unusual, 
for instance, for a student to feel faint at the first sight of a 
very painful treatment, the intensity of the impression being 
so great. Experience in the wards is full of intense, vivid 
impressions including the intense satisfaction which comes from 
the ability to relieve suffering and to actually render help to 
some known or present individual. 

In this connection it is important to remember that fatigue 
from over-study, from the emotional strain (more or less con- 
stantly present when surrounded by sickness, worry, and sorrow) , 
from over-practice, and from monotonous routine (when carried 
on at the expense of aims and standards) has the directly 
opposite effect to intensity ; that is, it greatly inhibits the process 
of fixing, remembering, or learning. This should be carefully 
considered both in the classroom and in assigning duties in the 
wards. 

The Law o£ Association is closely akin to the Law of Exer- 
cise and states that, in teaching, we must put together those 
things which we wish to go together. If we wish certain ideas 
or feelings to be associated in the mind, that is, to form habits 
of thinking or feeling; or if we wish certain thoughts and feelings 
to be associated with and control bodily responses or conduct, 
then we must teach them together remembering the importance 



44 METHODS AND PRINCIPLES OF TEACHING 

of repetition, intensity, recency, and satisfaction as illustrated 
in the following: 

Teaching Principles. — If we wish students to understand and 
apply the principles underlying any procedure or nursing meas- 
ure we will teach them together so that they will always function 
together. For instance, in teaching how to boil a rubber rectal 
tube we will teach the method of boiling rubber; that is, the 
facts common to all rubber, in other words, the principles. 

Teaching Skill. — If we wish students to become skilled in 
nursing procedures we will teach the elements which go to make 
up skill; that is, form and execution, the presence of the first 
factor only entitling it to the rank of art and giving us the right 
to speak of the art of nursing. 

Form or style is defined as what the individual does deliber- 
ately to influence movement — ^thought or feeling is associated 
with the bodily response, in past experience, and controls it. 
Hence we say, she plays the piano "with expression'^ or has "good 
form" in playing tennis, or "style" in writing or in dressing, or 
intelligence, skill, and sympathetic understanding in nursing. 

The value of form or style is that the consciousness or pres- 
ence of form not only gives aesthetic pleasure but the thought 
control upon which it depends is what makes it capable of 
attainment and development and also capable of the form or 
skill being transferred to other things and to other people. For 
instance, if in practicing beds one should notice that a student's 
movements are awkward or if she herself feels strained, one 
would be unable to help her unless one could analyze the process 
and show her which positions or movements are causing the 
awkwardness and strain. Without this ability to analyze, to get 
the right idea or thought control, one would have the same diffi- 
culty in overcoming strain or discomfort in a patient and, also, 
of teaching students how to do so. 

The principles of teaching form are those indicated by the 
Law of Association and of Exercise, the important principle 
being to always associate the right idea with the muscular 
act — ^the thought with the deed. Mind-set and the law of 



PRINCIPLES AND PRACTICE OF NURSING 45 

effect play their important part here as in other forms of 
learning. 

Execution, on the other hand, is merely a mechanical move- 
ment with little thought, and therefore little control, involved. 
It is defined as merely forming the right connection between 
the stimulus and the response or movement. It is the how of 
doing things, the factor in skill which, perhaps, we have mostly 
stressed in the past — ^not that it needs less emphasis in future 
but that form, the other factor, needs more. 

The principles of teaching execution are also indicated by 
the above laws, the emphasis being on practice — ^the try, try 
again — ^regarding those factors which make for success, dis- 
couraging and eliminating those which hamper and annoy. 

It must be mentioned here that teaching form, getting the 
right idea, does not mean making studied movements. Watching 
the hands or feet, all forms of self-consciousness should be 
avoided, attention being centered on the thing to be done and 
the results. 

Teaching Standards. — If we wish the students to understand 
and use standards in testing and evaluating their knowledge, 
work, or skill, then each thing and each step in a procedure must 
be measured by its effect and due regard for the safety and 
comfort of the patient, its therapeutic effect, the economy of 
time, energy, and materials, the finished appearance of the work, 
and the adaptability of the procedure to other situations, etc., 
in order that they may build up the proper associations and have 
practice in doing it. 

Teaching to Think. — Thinking is defined as the method used 
to direct and control the course of our experience so as to attain 
the desired result whether it be character, knowledge, or skill. 
It implies mind-set, interest, concern, responsibility for the out- 
come. If we wish our students to learn to think we must pro- 
vide such practice as analyzing situations or facts into their 
elements, as in associating cause with effect — through the obser- 
vation of symptoms, the effects of drugs or treatments, the study 
of the cause of their own success or failure in getting results 



46 METHODS AND PRINCIPLES OF TEACHING 

desired in a given treatment, or in planning their work and 
study as a whole. 

Such questions as the following which ask why and how give 
practice in thinking: 1. Why is an accurate taking of the pulse 
a valuable source of information concerning a patient's condi- 
tion? 2. How would you avoid increasing shock following an 
accident, or an operation? 3. Why would we expect an increased 
rate of respiration in pneumonia; a decreased rate in diabetic 
coma? 4. How may a nurse increase the amount of food eaten 
by a child who does not eat enough food? 5. Why does a patient 
suffering from pleurisy usually lie on the affected side? 6. Why 
do we apply an ice cap to the head when giving a body hot 
pack? 7. How may a nurse measure the efficiency of a treatment 
she has given? 8. Why must we keep a child, suffering with 
Potts^ disease, in his shell, when giving the necessary nursing 
care? 9. How would you prepare for an operation in the country 
where there are no hospital facilities available? 10. Why is the 
use of a hot water bag to relieve pain, in an undiagnosed acute 
abdominal condition, contra-indicated? 11. How might a nurse's 
responsibilities in the care of a patient suffering with a com- 
municable disease, differ in a hospital and a private home? 
12. How do we determine the amount and kind of nursing care 
it is desirable to give a patient? 

All questions which centre the thought around the patient 
such as why a patient will not or cannot eat his breakfast, or 
cannot sleep, or why he looks or is uncomfortable, etc., and 
how to overcome the difficulty call for and give practice in 
thinking. 

Another method of stimulating thought, discussion, or debate, 
is to repeat to the class general statements frequently made and 
believed by many to be true, such as: 1. Frequent bathing, 
more than once or twice a week, is injurious. 2. Drinking ice 
water before meals is injurious. 3. Drinking tea or coffee is 
injurious. 4. Candy for children is injurious. 5. Cleansing the 
mouth and teeth are unnecessary because Italians have beauti- 
ful teeth and do not cleanse them as we do. 6. Hot drinks after 



PRINCIPLES AND PRACTICE OF NURSING 47 

operations are better than cold drinks. 7. Always avoid turning 
a patient more than necessary. 8. Early to bed and early to rise 
make a man healthy, wealthy, and wise. 9. Square corners in 
bed-making are better than envelope corners. 10. Practice makes 
perfect. 11. A workman is known by his tools. 12. Cold night 
air is injurious. 13. Flowers in a sick room at night are injurious. 
14. A change (such as from ward to classroom) is as good as a 
rest. 15. A bed with a patient in it can be made more quickly 
than an empty bed. 

Teaching Qualities of Heart and Mind. — The same laws 
of learning hold true for all the abstract qualities, such as 
loyalty, imagination, sympathy, kindliness, initiative, altruism, 
adaptability, judgment, self-control, etc. These should be 
analyzed and explained by attaching or associating them with 
as many, varied, concrete illustrations or examples as possible. 
In teaching procedures, for instance, the students should be 
encouraged to give (in addition to facts, standards, etc.) exam- 
ples of conduct relating to it which would show adaptability, 
good judgment, initiative, sympathy, etc. For instance, in 
making a bed a student can learn adaptability, consideration 
of the needs of others, good judgment, and self-reliance in 
deciding how much clean linen to use for her patient. If, how- 
ever, the headnurse tells her always just what she may use, or 
there is a routine which regulates what is used and the linen 
closet locked and the key kept by the headnurse, then the 
student can learn none of these self-directing qualities. The 
conduct of students both in the classroom and in practical 
experience offers many such illustrations and will show many 
more with conscious application of the Laws of Learning to 
their development. 

The Project Method in Teaching and Learning 
This method is, according to modern thought in education, 
an ideal (at least for certain subjects) which we should strive 
for, because it is based upon and is in accord with the Laws 
of Learning. 



48 METHODS AND PRINCIPLES OF TEACHING 

A project is defined as a purposeful activity carried to coiU' 
pletion in a natural setting. To our students who have chosen 
the profession of nursing, the whole course is a project. They 
have come with the purpose of learning to nurse and expect to 
learn by actually taking care of patients in the hospital. The 
students have a purpose, everything they do is for a purpose 
having a social value and use. The setting, therefore, is natural, 
the students learn by doing and have all the satisfaction of 
seeing the results of their activities. 

This whole or larger project may be broken up into smaller 
and smaller projects, the patient being the centre of interest, 
in each project, around which aims, principles, methods, skills, 
knowledge, standards, and attitudes, etc., revolve. 

Dr. Kilpatrick has given the following classification of projects 
which can be readily adapted to our course in nursing as illus- 
trated below; other projects will readily suggest themselves to 
teachers and students. 

1. The Producer's Project. 

2. The Consumer's Project. 

3. The Problem Project. 

4. The Drill or Specific Learning Project. 

1. The Producer's Project, in which the purpose (student's 
purpose) is to produce something, as in the following: 1. Pre- 
paring a plan of daily nursing care for each patient, giving 
observations, readings, and references (such as anatomy, physi- 
ology, psychology, pathology, the medical history, and com- 
munity health reports, etc.) which explain the plan. Such a 
project gives practice in applying knowledge, in thinking, reason- 
ing, and planning, as well as developing such qualities as initia- 
tive, judgment, and a sense of responsibility. 2. Carrying out the 
actual nursing care of the patient based on such a plan or pur- 
pose, the plan being modified as the daily needs of the patients 
indicate and the student being responsible as far as her capacity 
as a student will permit. In such projects the students may build 
up associations previously emphasized such as the relationship 
of cause and effect, etc. 3. Each procedure or duty may form a 



PRINCIPLES AND PRACTICE OF NURSING 49 

simple project if prompted by a purpose and a sense of respon- 
sibility for the result — not just carrying out an order. 4. Plan- 
ning, preparing, and serving diets based on the nutritional needs 
of the patients; or planning, serving, and encouraging a patient 
to eat and enjoy his meals when the nature of the disease, loss 
of appetite, likes and dislikes, mental depression, or racial habits 
make this a difficult problem. 5. Group project — the preliminary 
group may accept the responsibility of arranging with the head- 
nurses, through a committee, and organizing their group, to make 
all the empty beds for a certain period, or for giving a certain 
number of baths, etc., correlating with the instruction and prac- 
tice in the classroom. 6. A complaint from the laundry of excess 
laundry, or stained linen, or of articles received, such as instru- 
ments, pillows, etc., which should not be sent down; or com- 
plaints of food wasted, thrown in the garbage, and similar prob- 
lems may be the occasion for a group project to solve the problem. 
7. A study may be made by one or more students of a variety of 
patients all suffering from the same disease, such as cardiac 
disease, diphtheria, diabetes, etc., in order to formulate the prin- 
ciples of nursing care for such diseases. 8. A group of students 
may work out the best way of setting up and using various trays, 
or of serving meals hot, attractively, on time, etc., or a system 
of giving and checking medications, or of working out the ward 
time slips or assignments for a day or a week so as to give the 
best care to the patients and the best experience for each student. 
9. A student may make a visit to a patient's home (under proper 
direction), or to an interested social agency, or to a district from 
which her patients come or go, in order to better understand her 
patients and their needs. 10. A group may make a survey of the 
hospital, the health and social resources of the city, study the 
hospital report and reports of vital statistics with a view to 
understanding the community needs and the school and hospital 
relationships. 11. Keeping various records such as charts, case 
studies, note books, personal health records, a scrap book of 
clippings or reference readings, etc., and oral or written reports 
of visits and surveys. 12. Making a plan of the day's work, 
week's or month's work as a whole including the course of study. 



50 METHODS AND PRINCIPLES OF TEACHING 

13. An expected visitor or a need felt in the hospital or by the 
students themselves may be the occasion for a review demonstra- 
tion planned, organized, and given by the students. 

We may illustrate by outlining the last project as actually 
carried out by a group of students. 

A Group Project 

Project. — The students in the preliminary or pre-clinical 
group had been in the wards for a short period each day serving 
the patients by making beds, giving morning and evening care, 
making them comfortable in various ways, helping to serve and 
feed their patients, and various other measures taught in the 
preliminary course. 

While doing so they daily encountered difficulties and prob- 
lems which, when discussed in class, were found to be fairly 
common to the whole group. Many of the difficulties were due 
to inexperience and failure of the students to adjust to the many, 
varied situations presented; some, however, were due to condi- 
tions over which the students had no control, such as lack of 
system in planning, assigning duties, giving adequate directions 
in assignments, and in general lack of leadership; some were 
due to inadequate individual equipment, and to such problems 
as lack of linen, torn linen (revealed on unfolding), or to lack 
of judgment in the use of linen or supplies; some were due to 
unnecessary interruptions during the treatment being given. 
The problem which seemed to give the deepest concern and 
was mentioned most frequently was the fact that there were 
so many different groups — headnurses and affiliating students 
from different schools and students in the home school taught 
by different instructors — each having a different method and 
different standards in nursing, all of which made it very con- 
fusing and difficult to measure up to standards which they 
desired. 

The students were finally asked whether they (teacher and 
students) as a group could do anything to help solve this prob- 
lem and, if so, what were their suggestions. Among other useful 
suggestions given, one was that we give a demonstration show- 



PRINCIPLES AND PRACTICE OF NURSING 51 

ing how the students were being taught and the standards they 
were expected to maintain in the wards. 

The teacher noticed that, while some students looked eager 
and pleased, a few looked rather dismayed. She, therefore, 
expressed her appreciation for the suggestion and enthusiastic 
interest in the worth whileness of the project and also her com- 
plete confidence in the ability of the group, stating that she 
had often been amazed at the executive ability and versatile 
talents displayed by, not just a few members of a group of 
student nurses but by all when giving a "stunt" party, an enter- 
tainment, or play. 

The group were asked to get together and think it over, the 
teacher warning them of difficulties ahead (such as the impor- 
tance of demonstrating a skilled, finished piece of work, accurate 
in every detail, and the amount of time which would be required 
for planning and practice with an already heavy program) and 
stipulating that, if they planned to give it, the whole group 
must be united in feeling and purpose and all must share in 
both the planning and the demonstration. 

The following day, a committee came to the teacher with a 
tentative plan, stating that they had all met together the pre- 
vious evening and had formed their committees with duties 
assigned and drawn up the plan which was in the form of a 
three-act play with certain features "to give the necessary touch 
of humour.'^ 

The plan was accepted, the teacher giving a few suggestions 
and expressing confidence in their good taste and judgment in 
avoiding any reference which would cast any reflection on the 
work of any other group or person, or cast any shade of dis- 
pleasure over the evening's enjoyment, its whole purpose being 
to create harmony and not disharmony. 

The students were told to go ahead with their plans, the 
teacher assuring them of her interest and desire to give any 
help which they felt necessary. The next few weeks went 
uneventfully by and the teacher, somewhat concerned, heard 
nothing further about the demonstration, but restrained her 
anxiety to make inquiries which might seem to show lack of 



52 METHODS AND PRINCIPLES OF TEACHING 

confidence and so spoil everything. However, as the date set 
and the Christmas festivities were both approaching and might 
interfere with each other, the students were told the demonstra- 
tion might be postponed. They were very disappointed as they 
were bringing the Christmas spirit into their play so plans were 
resumed. 

Very soon representatives from different committees came to 
ask permission to have or to do certain things but the students 
themselves made all the arrangements, carrying everything to 
the hall they selected, except things too heavy for them to move, 
and in everything took complete responsibility. 

Posters designed and prepared by the students were posted 
in good time. The program given below was prepared and 
typed by the students themselves and there were plenty of them. 
A rehearsal of the play was given on the evening preceding, to 
which the superintendent and teacher were invited. 

^'Daughters of Eli" 

wish you 

PLEASANT DREAMS 

in 

Prologue and Three Episodes 

— 1 — 
PICTURES AND MEMORIES 

Florence Nightingale Period of 1872 

Sairey Gamp The Henry Street Nurse 

— 2 — 

A NIGHTMARE 

DiflSculties and Problems in Ward Adjustments 

— 3 — 

THE SUPERVISOR'S DREAM 
"Each bit of work you do is someone's dream'^ 



Demonstration 

by 

Pre-clinical Class, Yale School of Nursing 
Chapel December 23, 1924 



PRINCIPLES AND PRACTICE OF NURSING 53 
DEMONSTRATIONS 

(Group 1) 

A. Open bed 

Arranging and dusting unit 

B. Closed bed 

C. Ether bed 

(Group 2) 

A. Care of hair 

Larkspur cap 
Shampoo 

B. Morning care 

Mouth 

Bath 

Bed 

Hair and nails 

C. Cardinal symptoms 
Evening care 

Mouth 

Face and hands 

Back 

Bed 

Hair 

(Group 3, Part 1) 

A. The recumbent patient 

Turning 
Lifting 

B. "Sitting up" in bed 

Back rest 
Gatch bed 
Use of pillows 
Tray or table 
Footstool 
Fowler's position 

C. Removing pressure, weight, and friction 

Leg support and sandbags 

Cradle 

Arm support 

Air cushion 

Cotton rings 

Pads 



i)^ METHODS AND PRINCIPLES OF TEACHING 

(Group 3, Part 2) 

Changing mattresses 

Two methods 
Bed transfer 
Wheelchair 

The demonstration, itself, was conducted just as a play— 
someone at the door, programs given out, ushers to escort to 
seats, music between the acts and during treatments which 
tended to be rather long with no explanations or speaking re- 
quired. Each student took part in several events, including her 
turn or turns when not on the stage at managing the curtain 
and the music — a gramophone. It would be impossible to de- 
scribe all the features which made the evening such a complete 
success for students, teacher, and audience. That the students 
were interested, that they had worked together as a group, that 
they had executive ability and the will and ability to solve prob- 
lems by themselves in the face of many difficulties, that they 
had worked and practiced unsparingly in a whole-hearted way, 
that they had a sense of responsibility, taste, good judgment, 
and a sense of humour which could be relied upon and that they 
had been keenly observant and alive to the needs of the patients 
in the wards, to the many difficulties and problems, and to the 
great opportunities as well as to their own inefficiencies were all 
evident in the good team work, thoroughness, and attention to 
detail displayed, the situations presented, the hidden talents 
and thoughts revealed, and above all in the delight of the audience 
— it all appeared so absolutely true to life in the wards. 

The students themselves felt on reflecting over the perform- 
ance that it was a little too long and that another time they 
would not try to show so much. One student had deliberately 
taken a little longer (five minutes) for her treatment than the 
time allowed her, in spite of anxious protests from the wings, 
because she had a feeling that the appearance of haste would 
have a bad effect and was contra-indicated for the comfort of 
the patient. The class agreed and decided that the fault was 
in planning to attempt too much. 



PRINCIPLES AND PRACTICE OF NURSING 55 

It was further recommended by the group that the more 
advanced nursing measures should be demonstrated later and 
that such demonstrations, to be given when the need suggested, 
should be an adopted, regular part of our program. 

II. The Consumer's Project, in which the purpose is to use, 
to appreciate, and enjoy something, the amount of learning in 
this, as in all projects, depending upon its purposefulness. Ex- 
amples might be: 1. A demonstration given by the teacher, a 
student, or group of students in a skilful, artistic manner and 
enjoyed. 2. An inspiring lecture given by the teacher and 
enjoyed, or a successful class recitation in which the students 
played the major part and in which their best efforts were 
developed and rewarded. 3. Satisfaction aroused by a patient 
who looks happy, comfortable, and attractive as the result of a 
student's nursing care; or by a patient who shows signs of im- 
provement. 4. The artist's appreciation of a successful piece of 
work such as an operation or dressing skilfully done, or a wound 
healing satisfactorily. 5. Appreciation of the devotion of family 
or friends, especially among the poor, or of the devoted service 
of a nurse or doctor to the patient. 6. Satisfaction from a pro- 
cedure successfully done, or the artist's appreciation of a beauti- 
fully kept linen room, utility room, kitchen, and ward with flow- 
ers attractively arranged and an air of comfort. 7. Satisfac- 
tion in making patients happy by meeting their needs — giving an 
interesting book to read, light congenial occupation, arranging 
patients so that congenial people will be together. 8. Enjoy- 
ing an interesting article or reference, or a bedside clinic. 
9. Satisfaction from a successful day's achievement and recog- 
nition and appreciation of good team or group work in class- 
room, ward, or in social activities. 

III. The Problem Project, the student's purpose being ^'to 
solve a problem, to clear up some intellectual difficulty." The 
Producer's Project may include a Problem Project but the 
emphasis in the former is on the doing and the thing done, 
whereas in the latter the emphasis is wholly on the intellectual 
factor in solving the problem. Such projects would include: 



56 METHODS AND PRINCIPLES OF TEACHING 

1. Problems in making solutions and in preparing drugs. 2. Cal- 
culating and planning special diets. 3. All forms of study if 
purposeful. 4. Thinking through difficulties such as getting chil- 
dren or adults to eat and drink; behaviour problems in children, 
problems in mental nursing, putting patients to sleep without 
narcotics, preventing bedsores and constipation, etc., the modi- 
fication and adaptation of procedures, etc., to meet special needs 
such as conditions in the home. 5. Formulating principles of 
nursing by applying a scientific method to the study of procedures 
such as the various types of irrigations, baths, hot and cold 
applications, methods of cleansing and sterilizing articles, and 
to methods of preventing cross-infection, etc.; or to the study 
of special problems in nursing (social, mental, or physical) and 
to special types of disease; or, in the preliminary course, to 
the study of a hypothetical case as outlined below: 

Project Developed by the Preliminary or Pre-Clinical Group. 
— Toward the end of the pre-clinical period, the attention of the 
students was called to an article which stated that, by applying 
the scientific method to the study of health and the causes of dis- 
ease, greater strides had been made in the last seventy years (the 
period during which it had been applied) than in the previous 
two thousand years. 

The students were asked whether this statement suggested 
anything to them. To some it suggested little but others asked 
if this method could not be applied to nursing and, if so, would 
it not have the same result in nursing as in medicine and other 
fields. It was felt that before answering this question we would 
have to find out what the method used really was. The stu- 
dents were asked if, in their studies in the various science labo- 
ratories, in the wards, or in their reference reading, they were 
conscious of a definite method being used. They were asked to 
think about it, and also to read the chart of a patient in the 
ward, and a social case record prepared by a social worker in 
see if the method used by the doctor or the social worker in 
making a diagnosis (and prescribing treatment) was the same, 
for instance, as that used by the bacteriologist in finding out 



PRINCIPLES AND PRACTICE OF NURSING 57 

the kind of bacteria, if any, in a given specimen of sputum. 
They were to be prepared to discuss this in the next class with 
a view to analyzing the steps in the method or process. Refer- 
ences, including a study of their own laboratory notes, were 
mentioned. The findings and questions of the group were dis- 
cussed in class, charts were read and discussed, and the steps 
in a scientific method of study were finally outlined. 

The problem then before the class was to answer the question 
raised by the class as to whether this scientific method could 
be applied in the study of patients for the purpose of prescrib- 
ing the nursing care for each patient, based on his individual 
needs, as clearly and scientifically as medical care is prescribed. 

It was felt, the teacher said, that at present our content of 
nursing knowledge and our nursing program tended on the whole 
(with, of course, exceptions) to be too general. For instance, 
the nursing program in a ward may state that all patients must 
have a bath on admission, head washed and fine-combed, etc., 
and all must have at least two baths a week; that all will have 
the same number of meals, much the same menu (unless other- 
wise ordered), the same fluids, at the same hour; that all will 
have evening care at the same time and the same method of 
morning and evening care is given for all; that all patients will 
have a rubber on the bed regardless of their condition; that all 
the curtains should be at the same height, all beds, tables, chairs, 
etc., be in the same position, that all be dressed alike, that all 
have visitors at the same hour; that all patients will be ready 
for "rounds" at a certain hour, etc. 

It was stated that while much, if not all, of this uniformity 
was desirable, the point was that it was not all that was desir- 
able and necessary. It is, as it were, nursing in the gross, the 
resulting tendency being that, having given a patient morning 
care and breakfast, no further attention, unless prescribed by 
the doctor, is often thought by students to be necessary until 
lunch ; and, having given lunch (regardless of how much or little 
he ate) no further thought is given until supper, and so on. 
Whereas what is needed is a program of nursing for each patient, 



58 METHODS AND PRINCIPLES OF TEACHING 

for each day, and for all day just as doctors study and prescribe 
according to the patient's specific needs. 

Students who nurse patients instead of a patient — ^that is, 
students who nurse in a routine way, giving much the same 
care to all patients regardless of their individual needs — do not 
learn to observe, to think, to discriminate, to judge relative 
values, to use good judgment, to use initiative, to be reliable, 
to feel for and to sense the needs of the individual. Because of 
this tendency, hospitals, doctors, and visiting nursing and public 
health organizations feel it necessary to make rules which apply 
to all cases and to all nurses. For instance, that in a children's 
clinic all the children who come to the clinic must be weighed 
regardless of whether or not the weight were a factor in the 
disease and regardless of the nurses' valuable time taken in 
doing it. In a visiting nurse organization it is usual to rule that 
all post-partum patients be bathed for a certain number of days 
after delivery regardless of the varying needs and conditions of 
the patients, although one may be robust and another delicate, 
undernourished and rundown. 

This is not because hospitals or visiting nurse organizations 
desire to make rigid rules — such rules grow up largely because 
mistakes have shown that thought and good judgment on the 
part of the nurse cannot always be relied upon. Rules in the 
form of directions are, of course, necessary, but students must be 
taught and must learn to think, to discriminate, and to use good 
judgment in interpreting and applying such rules to meet the 
needs of the individual. 

Another statement made was that we should make a better 
use and more direct application of the sciences, and other sub- 
jects taught, in developing our plan of nursing care which, it 
was felt, could, in part at least, be developed from such knowl- 
edge. For instance, should the following diagram show the 
correct and most fruitful relation between the basic sciences, 
medicine, and nursing? That is, while medicine draws directly 
from and is dependent upon the basic sciences, and nursing 
draws from medicine, should not nursing also derive its facts, 



PRINCIPLES AND PRACTICE OF NURSING 59 

principles, methods, spirit, and imagination directly from 
science? 



Medicine 




^ItTrsJng ^-— ^ Sciences etc. 



The problem then before the class was to find out, by study 
and experiment, whether this scientific method could be applied 
to nursing and whether by so doing a definite organized content 
of nursing knowledge could be built up as had resulted in medi- 
cine and other fields. 

The class was then asked to mention cases or conditions they 
would like to study. Hypothetical or imaginary patients were 
chosen because the present aim was to emphasize the use of a 
method and the direct application of facts and principles from 
the sciences, the principles and practice of nursing, and other 
subjects. It was recognized and emphasized that our plan, of 
necessity, would be incomplete because of our present limited 
knowledge and experience and that any plan is only sound and 
workable (and when dealing with people, justifiable and safe) 
when based on adequate knowledge, understanding, and thorough 
testing. The plan formulated would therefore be tentative — this 
principle being inherent in a scientific method — and would be 
tested and supplemented later by classroom discussions, medical 
and surgical lectures, pathology, etc., and by clinical experience 
in caring for not only one but many patients showing varying 
stages and manifestations of the same disease. 

The first study selected was a patient suffering from cardiac 
failure. The problem was how to make Mrs. ? comfortable 
and happy and to further her recovery and return to normal 
living. The problem stated, the second step was to gather all 
the facts from the various resources which would help solve the 



60 METHODS AND PRINCIPLES OF TEACHING 

problem. For instance, what would a study of the anatomy and 
physiology of the heart tell us about the effect on the circulation, 
and on the function of other organs, with resulting symptoms? 
What possible effect would such a disease have on the social life 
of the patient — her work or play, her family and the community? 
What effect would it have on her mental attitude, her interests 
and use of leisure, and her health habits such as exercise, diet, 
nutrition, weight, eliminations, and sleep, etc.? What effect 
would the possible prognosis have on the patient and so on? The 
third step would be to reflect upon the facts revealed — analyz- 
ing, weighing, comparing, making inferences, associating cause 
and effect, and selecting facts useful in solving the problem. 
The fourth step would be to draw conclusions and to formulate 
a plan of nursing care which would include and provide for all 
the items mentioned. The fifth step would be to apply and 
test out the plan, verifying, modifying, and adding to it with 
fuller knowledge and richer, broader experience in the actual 
care of patients. 

Further practice was given in the study of other hypothetical 
cases such as a patient suffering from disturbed function of the 
stomach, the intestines, the mouth, the kidneys, the glands, etc. 
Later studies were made of cases selected, such as patients suffer- 
ing from diabetes, hyperthyroidism, bedsores, gonorrhea, syphilis, 
constipation, etc. 

The results plainly showed that a scientific method of study 
could be applied to nursing and that by so doing a definite, 
organized body of knowledge could be developed. 

IV. The Drill Project or Specific Learning Project, in which 
"the purpose is to acquire some item or degree of skill or knowl- 
edge" such as attaining a certain speed and accuracy in action, 
or in mental alertness, in thinking, in making decisions, in 
figuring, in memorizing, and in keenness of observation. 

All forms of practice carried on individually or in groups in 
the classroom, wards, or in the student's free time would be a 
Drill Project providing that the students felt the need of prac- 



PRINCIPLES AND PRACTICE OF NURSING 61 

tice and, therefore, had a purpose in doing it. For instance, a 
standard set by an individual or group to be reached by the 
end of a week or month would be a project requiring preparation 
and practice in the student's free time, the amount of practice 
depending upon the capacity of the individual student thus mak- 
ing provision for this very important factor of differences in 
ability. 

Arranging the course in topics, outlining and posting the 
content (in terms of knowledge, skills, standards, and attitudes, 
etc.) to be covered or accomplished by a definite time makes 
study and practice on an individualized basis possible. By so 
doing the brighter students are not held back (with resulting 
loss of interest, effort, and the satisfaction which leads to fur- 
ther effort and learning) ; or the less alert discouraged by their 
seeming failure and lack of success, with its resulting inter- 
ference in learning. 

By so doing we shall be able to maintain our high standards 
for all, but the progress and rate of progress or achievement 
for each student will be measured not only in relation to this 
common standard but in relation, also, to capacity which varies 
with each student. 

While it is desirable and necessary to make provision for 
individual differences in ability, as indicated above, or by divid- 
ing a class into sections based on their ability, more emphasis 
and encouragement should be given to group activities, group 
projects, and group standards and achievements. For it is only 
by sharing in the aims, difficulties, and problems of the group 
that desirable social attitudes and appreciations can function and 
develop. 

Developing the Project. — As the name project implies, the 
students should, as far as possible, be made responsible and 
left to carry it out alone. Before doing so, however, the teacher 
must insure that the students know exactly what it is they aim 
to do and that (although they know or perhaps because they 
know, there will be difficulties and problems ahead) the whole- 



62 METHODS AND PRINCIPLES OF TEACHING 

hearted interest of the whole group is aroused and not just that 
of a few stars in the class — in other words, that it is a real 
student project. 

A perhaps equally important factor to insure is that the 
project fits in with the major topic being studied and that, 
while difficult enough to offer a challenge, it is not too difficult 
to be accomplished with success and satisfaction. Otherwise 
there will be a sense of failure, discouragement, little learning, and 
fear of venturing on a second project. The necessary resources 
should be available, such as equipment, references, etc., and the 
guiding hand of the teacher who, while showing enthusiasm for 
the project and confidence in the ability of the students, knows 
when and how to offer help and encouragement. It seems hardly 
necessary to add here that the difficulty of the project would 
be considered not only in relation to the student's ability but 
to the safety and comfort of the patients. 

In the opinion of the writer, students should not be given, as 
a project, the demonstration of a procedure which has not first 
been demonstrated to them. This would seem unfair both to 
the student and the class because of her lack of experience and 
because of the importance of first impressions and the danger 
of forming inaccurate mental images, ideas, and habits. Stu- 
dents vary greatly in their ability to interpret and form mental 
images from written or spoken directions of a procedure involv- 
ing many details, and, in all, such images are apt to be faulty. 
Students learn best, by seeing and forming a mental image of 
the whole process, then analyzing into separate steps and focus- 
ing attention and effort on the more difficult ones. Seeing a 
finished skilful demonstration is also more likely to create a 
desire to imitate, to produce. 

Having learned a procedure, a project might be to adapt 
that procedure to a different situation, such as a different type 
of patient, or to the clinic, or the home. 

In addition to a demonstration the development of a project 
may call for an inspiring, illuminating lecture by the teacher 



PRINCIPLES AND PRACTICE OF NURSING 6^ 

to arouse purpose, or to reward and stimulate further effort. 
Experts in the various topics may be called in such as the 
dental hygienist on the care of the mouth, the physiotherapist 
on the massage of the back for comfort, the social worker on 
the social aspects of admitting or discharging a patient, etc., 
a nurse proficient in mental nursing on the mental aspects of 
admitting or discharging, or in special cases such as diabetes, 
or nephritis. In addition there may be class recitations and 
drill lessons, all developed in keeping with the project method — 
purposeful activity on the part of students. 

The following description of a method of teaching called 
Purposing is taken from the Courtis Standard Research Tests 
and is highly recommended: 

"Class work is markedly divided into phases, part teacher 
controlled, part pupil controlled. Teacher in control only dur- 
ing periods of stimulation and reflection; pupils in full control 
during periods of activity with teacher assisting. Pupils^ activity 
consists of the planning, executing, judging essential to accom- 
plishment of purposes. Lessons are set and appraised by pupils. 
All class work and disciplinary control is almost completely 
socialized; that is, organized and administered by the group, not 
by the teacher. Almost no use of questions, directions, etc., by 
the teacher as a means of recitation. Emphasis is placed on 
purposes, achievements, standards, ideals, not on results in terms 
of knowledge and skill. There is no, or very little, learning in 
the sense of committing to memory except as a means to an end. 
Much pupil directed reference reading, and much use of rich 
supplemental material. There is also little organization of sub- 
ject matter in logical sequence, but order and content of lessons 
are determined almost wholly by purposes. There is also little 
organization of subject matter in logical sequence, but order 
and content of lessons are determined almost wholly by purposes. 
There is complete acceptance by the children of the teacher as 
one of the group and almost perfect freedom of expression or 
of appeals for assistance." 



64 METHODS AND PRINCIPLES OF TEACHING 

Teaching a Lesson in the Principles and Practice 
OF Nursing 

The lesson may be considered under two headings — I. The 
Teacher^s Preparation of the Lesson — what and how to teach; 
11. The Method of Presenting the Lesson to the Class. 

This may be considered under four headings: L The condi- 
tion or conditions to be met and a clear statement of the prob- 
lem to be worked out. 2. The underlying principles, causes, and 
effects to be worked for. 3. The method or procedure which will 
produce the desired result. 4. Supervised practice in the class- 
room. 5. The assignment, including theory and practice. 

I. The Teacher's Preparation of the Lesson. — In prepar- 
ing the lesson, all the factors mentioned above will have 
to be considered and provided for. In studying the con- 
dition, defining the problem and assembling her facts and prin- 
ciples a teacher will draw upon various sources of information — 
her own rich background of experience, text, and reference books, 
and a study of patients in the wards who are suffering from con- 
ditions for which the treatment might be given. The information 
then will be organized and arranged under headings and sub- 
headings in the order in which they will be used in developing the 
lesson. The method of presenting or of developing these facts and 
principles by skilful questions, class discussions, and other means 
will, also, form part of a teacher's class preparation. 

The equipment for the demonstration and for practice should 
also be prepared and arranged in the most convenient manner 
and order of use so that both demonstration and practice may 
proceed in the most efficient way and in accordance with the 
standards of work set. 

II. Presenting the Lesson — 1 and 2. Stating the Problem — 
The Underlying Principles and Effects Desired. — It is most 
important that students understand the problem; that is, the 
conditions which indicate the nursing procedure or treatment 
under consideration, and the results it is expected to bring about. 
Such conditions and the results we desire determine our whole 



PRINCIPLES AND PRACTICE OP NURSING 65 

method of procedure and are, therefore, considered in the writer's 
text book. For instance, prefacing the discussion of the morn- 
ing toilet, some of the probable conditions of patients in the 
morning are presented. The same principle would apply in 
teaching bed-making, or an enema, or a cold sponge bath. 

This presentation centres the thought on the patient and 
guides us in selecting, weighing, and carrying out each step in 
the procedure by relating it, on the one hand, to the condition 
and on the other, to the results or effects desired. It develops 
the underlying principle and gives each step a meaning and a 
purpose. It teaches students to analyze, to reason, to look for 
results, and to know how to get them. These principles can 
be developed by skilful questions drawing upon the student's 
own experience, the basic sciences, and their text and reference 
books. 

When the nature of the nursing procedure or treatment per- 
mits, a real patient is desirable. In any case, the history and 
discussion of a real patient in the ward, for whom the treat- 
ment or procedure will be beneficial, may be taken as the 
motive for teaching and learning. A broader understanding 
of the principle may then be developed by showing its use 
and application in the nursing care and treatment of other 
varied conditions and diseases. Such cases studied and pre- 
sented by the students form a basis for a very fruitful class 
discussion and a rich human background and motive for the 
demonstration of the procedure. 

3. The demonstration should be a finished work of art. Cer- 
tain aspects relating to it have already been discussed. Here it 
may be considered (taking a treatment to be given to a patient) 
under the following headings: (a) Selection and preparation of 
the equipment and materials, (b) Preparation of the immediate 
surroundings of the patient, (c) Giving the treatment, (d) 
Making the patient comfortable and clearing away utensils, etc., 
and (e) Observing and recording results. As previously stated, 
in order to get certain desired results and to avoid other unde- 
sirable results, each article or material will have to be carefully 



66 METHODS AND PRINCIPLES OF TEACHING 

selected and handled and each step in the above phases of the 
procedure carefully carried out. 

When a procedure is complex, with many factors and types 
of skill involved, the demonstration may be given in parts. 
For instance, a complete morning toilet includes the care of 
the mouth, hair, nails, and body and, in addition, making a bed 
with a patient in it — the latter, in itself, being usually found 
difficult and requiring much practice. Each division, also, has 
its own body of theory and special technique. The whole, how- 
ever, should finally be assembled as a complete demonstration 
in the way in which students are expected to give it. 

Again, the preparation for the treatment, or the treatment 
itself, may involve so many factors that it may be desirable to 
teach them in parts, finally assembling as a whole. For instance, 
it often arouses interest and gives a clearer picture of the whole, 
in such treatments as catheterization, if the instructor previously 
prepares for the treatment (sets the stage, as it were) and 
begins her demonstration with the treatment itself, then later 
showing how to prepare for it. 

Sometimes the preparation of the treatment and of the patient 
may proceed together; for instance, while water is heating or 
articles are boiling, the patient may be partly or wholly pre- 
pared. Again, the treatment and the clearing away may be 
done, in part, together; for instance, while a patient is using 
the bedpan following an enema, it is often permissible to leave 
and clear away the utensils. 

The demonstration given in the classroom, by relating each 
step to the condition, to the underlying principle, to the results 
desired and, also, to the standards of work given, should make 
all such adjustments or adaptations clear. 

Recording a treatment and its results should also be included 
in a demonstration, not only to emphasize the importance of 
recording necessary information neatly, concisely, accurately, 
and promptly, but to establish a habit of keen observation, 
of associating cause with effect (and vice versa) and a feeling 
of concern and responsibility for getting results. 



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72 



PRINCIPLES AND PRACTICE OF NURSING 73 

Following each demonstration, a typewritten or mimeographed 
copy of an outline of the procedure (such as the following) may 
be given to each student. It is suggested that with each outline, 
space be left for notes or additions or alterations, made by the 
students, or instructor, and that the outlines be kept in the 
elastic form of a loose-leaf book thus making provision for 
future alterations and additions. A second convenient and 
admirable method is to have the outlines printed and bound 
in an inexpensive book form, such as the excellent and attractive 
manual of the Philadelphia General Hospital. 

The following outline represents an effort to place the pro- 
cedure in its proper setting in relation to other controlling 
factors. The purpose is to show that the procedure is merely a 
means to an end and not the end itself, as its undue emphasis 
in the past (or rather the lack of emphasis on results, on prin- 
ciples, and standards) has tended to make it. 

Method of Use: It is suggested that, at least, the procedures 
taught in the pre-clinical period might be printed or mimeo- 
graphed on such a form and using such headings. The teacher, 
having taught a lesson and demonstrated the procedure, would, 
in the usual way, give each student a copy. The lesson could 
then be summarized (always an excellent custom) by having 
teacher and students together, through class discussions, check 
in the proper column the desired results, principles, and stand- 
ards which controlled or explained the reason for each step. 
For instance, the step ''close windows to avoid draughts'^ would 
be checked under "to stimulate circulation," ''to stimulate skin 
function," and "to stimulate sweat glands" because these desired 
results would probably be prevented by cold draughts. "Safety 
of the patient" and "comfort of the patient" would also be 
checked because both would be endangered by cold draughts. 

Each step could be checked in a similar way. Such a prac- 
tice carried on daily over a period of months would undoubtedly 
stimulate discussion and develop habits of thinking, of analyz- 
ing, of purposing and feeling concern for results and of know- 
ing just why each step was taken and which step brought about 



i 



74 METHODS AND PRINCIPLES OF TEACHING 

the desired results. A student^s reason for doing things would 
not then be "because we have always done it that way." It 
would also give a student a better understanding and a sounder 
basis for evaluating different methods of procedures taught in 
different schools. Nursing would not then be mechanical and 
empirical but rational and scientific. 

The constant practice in checking each step with proper 
standards would also establish high standards and the con- 
structively critical attitude necessary if students are to have 
any direction and control of their own progress. The whole 
practice is in accord with the teacher^s aim to help students 
to help themselves. 

After several lessons in which teacher and students work 
together, a second use might be to have the students take the 
outline home as an assignment and independently, or in small 
groups, think through the process and check under the proper 
headings. The results could then be discussed, verified, or cor- 
rected in the following lesson. A third use might be a similar 
one, but given as part of a test or reviewed lesson. Other uses 
will suggest themselves to teacher and students. 

By the end of the pre- clinical period proper habits of think- 
ing, in relation to procedures, should be established. Whether 
or not the advanced procedures should be presented and taught 
in the same form might depend upon results obtained and left 
to the discretion of the various instructors. 

4. Studenfs Practice in the Classroom. — In a previous dis- 
cussion it was stated that practice should, if possible, follow 
the demonstration immediately, provision being made for each 
student to practice under supervision. In planning her lesson a • 
teacher should see that sufficient equipment is provided and that 
it is easily accessible to all. If the amount of equipment or 
the number in the group makes practice under adequate super- 
vision difficult or impossible, the group should be divided into 
sections. 

Students may practice or work singly or in groups of two or 
more, depending upon the treatment. In many cases, a student 



PRINCIPLES AND PRACTICE OF NURSING 75 

may act as a patient. If there is marked difference in the ability 
of the members of the class, it is suggested that the group be 
divided into sections based upon their ability. Additional prac- 
tice with additional help and supervision may then be provided 
for the less skilful until they measure up to the standards of the 
group. Throughout the practice, emphasis should be placed on 
principles, on standards, on skill, on results, on progress and 
achievements for the individual and group. 

It is suggested that a procedure card such as Table I and II 
be given each student on which she may check off procedures as 
taught, and again after she has demonstrated her ability to do 
it satisfactorily. This card should follow the student from ward 
to ward so that each head nurse may be guided in her plan of 
teaching for each student. 

As has been suggested, the instructor should keep a record 
showing a group picture of all the procedures taught, and prac- 
tised by the students under her instruction and supervision. As 
already suggested this group record may be posted on a bulletin 
board and the students, themselves, may check off the procedures 
they have satisfactorily accomplished. This record is analogous 
to the outline an instructor in a classroom or science laboratory 
would keep indicating the demonstrations she plans to give in her 
course and the experiments to be carried out by the students. 

5. The Assignment. — For facts and underlying principles, 
students may be referred to the patients' charts and other 
records, and to text and reference books in nursing, medicine, and 
the basic sciences, etc. 

Practice may be assigned to individuals as their needs indicate. 
Practice for the group may be assigned in the wards. This may 
be planned in the form of a project. For instance, if the object 
is to practice bed-making, a committee appointed by the class 
may interview the headnurses on certain wards and make an 
inventory of the probable number of empty beds to be made. 
They will then make a contract with the headnurses to make 
a certain number of beds each day at a convenient hour and 
covering a definite period of time. The beds then would be as- 



I 



76 METHODS AND PRINCIPLES OF TEACHING 

signed to the members of the class in proper proportion. A 
schedule of the contract should be prepared by the group and 
a copy given to their teacher and to each headnurse. Such 
practice would be checked on the individual and group procedure 
records indicating the amount accomplished. All such practice 
should, of course, be carefully supervised and measured by the 
accepted standards. 

Before the students are permitted to go to the wards to carry 
out such a project they should understand that such practice 
should not only contribute to their own needs, but to the com- 
fort and happiness of the patients and the general efficient con- 
duct and management of the ward — for instance, that their 
service should be regular from day to day in time, in number of 
workers, in amount contracted for, and that their work should 
be finished and should measure up to acceptable standards. 

To train the students in observation, to focus thought on the 
patient and his condition, rather than on the procedure, the stu- 
dent should begin to keep an experience record even though the 
practice relates only to making empty beds — ^the bed belongs to 
a patient who is suffering from some disorder and the bed is 
empty because his condition or progress in recovery permits him 
to be up, all of which tells a significant story. 

Review Demonstrations. — Such reviews are very desirable 
and with proper stimulus, encouragement, and guidance may 
safely be placed in the hands of the students as indicated in the 
project described on page 50. 

The reviews may include both theory and practice and may 
be arranged weekly, monthly, at the end of a term, or whenever 
a summary or review is indicated. Sufficient notice should be 
given the group to allow for planning, for reading, for group 
discussion, and the necessary practice. 

Use of Examinations. — Some form of examination is usually 
felt to be necessary both for the students and teachers. But, as 
previously indicated, such tests should be in the form of self- 
testing measurements. Such self-testing should not be left solely 
to the end of any particular period, but should be a constant 



PRINCIPLES AND PRACTICE OF NURSING 77 

attitude of mind influencing and controlling conduct with a view 
to improvement, success, and the satisfaction which leads to 
further effort. The students themselves must see when their 
work is below standard, must be dissatisfied with it and desire 
something better before they will change, and conscious satisfac- 
tion must follow. This desire for improvement should be just 
as much a part of our mental and physical make-up as our 
appetite which normally tells us when we need food, how much 
we need, stimulates effort to get it, tells us when we have had 
enough and when we are satisfied. 

The examinations set at the end of any period (short or long) 
will be helpful if in the form of questions or a piece of work (such 
as a written or oral report, or paper, or demonstration) which 
indicates to the students what they should have covered, whether 
or not what they have learned is scattered, or organized and sys- 
tematized, and which tests their ability to apply and use their 
knowledge as independent workers in their practical experience. 
The real test of knowledge, skills, attitudes, and appreciations is 
in the actual care of patients both in the hospital and in the 
community. 

Questions given should not only test present ability, but should 
stimulate interest in further projects and study. 

As previously stated sufficient time should be given for 
thought, reading, discussion, planning, or practice. The com- 
pleted work should include a bibliography of the sources of 
information used. 

Use of Text and Reference Books, Etc. — It is said that 
"Books are, or at least ought to be, our servants, not our mas- 
ters," and that the ability to use a book to the best advantage 
is a very valuable accomplishment. 

The word ''servant" suggests something personal, something 
which belongs to us, a book which serves as a ready, convenient, 
and faithful guide. To use as a servant and not as a master 
means to go to it not as to something which, in itself, must be 
learned or to something which determines what we shall learn — 
what our lessons shall be — but to something which will provide 



78 METHODS AND PRINCIPLES OF TEACHING 

us with accurate facts, principles, methods and standards, etc., 
which we need in overcoming difficulties, solving problems, and 
developing projects in our practical experience. The book then 
becomes a useful tool which, like all tools, requires knowledge 
and practice in using if it is to serve to the best advantage. 

This mind-set or purpose in approaching any book — ^the feeling 
that we are going to get help in doing something in which we are 
Interested; the degree of feeling of success and satisfaction in 
receiving this help which makes its use seem worthwhile; the 
exercise or frequent use, through ownership, which makes a book 
seem a familiar, well-worn, and reliable friend or companion, all 
determine how much students will learn from using a book just 
as these laws of learning determine how much we shall learn 
from any activity or experience. 

The way to arouse this necessary mind-set is not by telling 
students what they can read and understand for themselves or 
by asking simply fact or memory questions from the book, or 
by simply following the outline, headings and paragraphs of 
the book; it is aroused by worthwhile projects, problems and 
thought questions which call for the assembling of facts (from, 
perhaps, different parts of the text book as well as from other 
books, etc.), the thoughtful analysis and organization of facts or 
principles, and their application in solving the particular problem 
at hand. We are all bored by hearing facts which we already 
know repeated and it is also a well-known fact that most people 
learn better by seeing or reading than by hearing. Students are 
never stimulated, their imagination and desire to learn are never 
aroused by hearing either teacher or students repeat something 
which they have read or can read for themselves. And it is well 
recognized that ''the facts which have had some place in our 
thinking are the ones which we retain for future use." 

Students vary greatly in their ability to use not only a text 

or reference book, but in their ability to recognize and use other 

sources of help available, such as their own experience, facts 

which are all about them in the open book of the wards, the ex- 

erience and example of teacher or fellow-students, charts, mag- 



PRINCIPLES AND PRACTICE OF NURSING 79 

azines, state or municipal bulletins, libraries and museums, etc. 
Students should be taught both how to use their text book — the 
use of index, table of contents, general plan of arrangement into 
large topics, sub-topics, principles and methods, with their 
uses and applications — and, at the same time, not to rely solely 
upon it. They should learn to recognize and follow cues and ref- 
erences in the text, or in their projects, or other sources of 
information such as mentioned above. 

It is important to remember here that if, in our enthusiastic 
desire to broaden the student's viewpoint and knowledge, and to 
put them in touch with a wide range of resources, we make our 
assignments too long or too difficult for the time available, and 
for the ability of the students to accomplish with satisfaction, we 
will defeat our own purpose. 

REFERENCES 

Bagley, William C, and Keith, John. — An Introduction to 

Teaching. 
Dewey, John. — Democracy and Education, 
Harmer, Bertha. — ''Methods of Teaching Practical Nursing"; 

The Modern Hospital, June and July, 1923. 
"Teaching and Learning by Practical Experience"; Annwal 

Report of the League of Nursing Education, 1925. 
Kilpatrick, William H. — Foundations of Method. 

Source Book in the Philosophy of Education. 

Stevenson, John A. — The Project Method of Teaching. 
Strayer, George D. — A Brief Course in the Teaching Process. 
Strayer, G. D., and Norsworthy, N. — How to Teach. 



SECTION IV 

TEACHING AND LEARNING BY PERSONAL EXPERI- 
ENCE IN THE WARDS, OUT-PATIENT DE- 
PARTMENT AND THE COMMUNITY. 

CONTENT OF THE COURSE OF STUDY 

We have previously stated that "the content of a course in the 
Principles and Practice of Nursing will necessarily include those 
ideals, attitudes, appreciations, knowledge, skills, and methods to 
be taught in the classroom; and that same content, made more 
rich, broader, more vital and lasting by its natural setting, which 
can be learned only by personal experience in the wards, out- 
patient department, and the community"; and that ''the course to 
be given in the classroom and wards should be considered, not as 
separate subjects, but as one organic, interrelated whole, each 
supplementing and incomplete without the other." Emphasis has 
been laid upon the fact that we have, in the situations presented 
in our wards, those factors in education most truly vital; that 
is, the opportunity for teaching and learning by doing — ^the 
intelligent carrying forward of purposeful activities in the 
natural setting of the wards. 

Subject Matter Organized Under Topics. — The content of 
the course, as presented in the field of experience in the wards 
and clinics, naturally groups itself, as indicated in the outline on 
page 24, into large or major topics each with its own, more or 
less, special content and contribution in terms of ideals, attitudes, 
appreciations, standards, knowledge, and skills. 

These major topics arise from the customary division of 
services into medicine, surgery, pediatrics, obstetrics, commu- 
nicable diseases, psychiatry, and (in nursing) community nurs- 
ing outside the hospital with a visiting nurse or public health 

80 



PRINCIPLES AND PRACTICE OF NURSING 81 

organization. In nursing, also, the preliminary course, or that 
portion of the course which precedes clinical experience in the 
above majors (and is, therefore, a foundation for all), is, itself, 
a major topic. 

The special content in each of these majors may, like the 
course as a whole, be determined by a job analysis of: 1. The 
insight, knowledge, and understanding of (a) the patients in 
a ward or clinic and the conditions from which they are suffering. 
Such knowledge, which depends upon the clinical material avail- 
able, while the most rich, fruitful, and lasting is apt to be quite 
variable, not within our control, and to that extent incomplete, 
so must be supplemented by (b) the organized, systematized 
course which is given in the classroom. 

The content or subject matter related to the patients in the 
wards or clinics might be arranged in lessons, the number de- 
pending upon the number of patients; or the patients might fall 
into groups according to the diagnosis, or the social aspects to 
be studied, or the various medical or nursing treatments pre- 
scribed. For instance, there might be several patients with some 
form of circulatory disturbance and the lesson might deal with 
a comparison of pathological conditions present, the causes, 
symptoms and signs, the mental, social, and economic aspects, 
the various treatments, their results, the prognoses, future pros- 
pects and plans for future welfare. Or, again, the lesson might 
be on a treatment such as a simple hypodermic injection or a 
hypodermoclysis, or a certain diet or drug given to different 
patients with the same or different diseases, for the same or for 
different purposes and with varying results. In all such lessons 
or discussions emphasis should be placed on the relation of the 
facts and underlying principles revealed and their use and 
application in the program of nursing care for the patient. 

Again, the lesson planned might be to bring out the different 
ways in which patients sleep or do not sleep; such as, slept four 
hours but restless, crying out in sleep; did not sleep but quiet; 
slept only after a narcotic; awake and restless due to pain; slept 
well from ? to ? (early evening), awake from ? to ? but slept 



^A^/tA 



82 METHODS AND PRINCIPLES OF TEACHING 

toward morning; other illustrations might be discussed, using 
the night reports as reference, and taking up in each case the 
conditions, possible causes, preventive measures and treatments 
with the purpose of formulating principles of nursing care 
relating to the important factor of rest and sleep. 

Many similar problems relating to the care of patients might 
form topics for discussion. 

2. A job analysis of the special skills in terms of (a) the 
duties, procedures, and nursing measures included in the medical 
and nursing treatment of the above patients and conditions ; and 
(b) the facts and underlying principles of such treatments which 
make nursing intelligent — give it meaning and content which lift 
it above the mechanical into the realm of science and art. 

The outlines given below illustrate an analysis of such duties, 
which a headnurse instructor in a pediatric service and a 
communicable disease service would hope to teach all the stu- 
dents assigned to her course, that is, to her ward. Similar out- 
lines would be kept in medical, surgical, and obstetrical services, 
etc., and, also, for the pre-clinical period. The spaces across 
the upper portion of the form are for the names of the 
students. 

Likewise it is recommended that on this form, or on a separate 
form, should be indicated and checked the teaching and experi- 
ence of the students in the care of those diseases which, it is felt, 
should be included in that particular service. 

An instructor in a classroom keeps a careful record of what 
sho has taught each student. This similar record, kept on the 
bulletin board outlining the content of the course in each ward, 
shows clearly to both teacher and students not only what has 
been taught in the classroom, but what has been taught and 
practised (learned by doing) by each student in the natural 
letting of the wards. It also defines the course and enables the 
student to grasp the content in terms of skills to be learned and 
to measure their progress in learning. Each procedure and ex- 
perience in nursing may be checked by the teacher or, better 
still, by the student giving her that added satisfaction in achieve- 







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PRINCIPLES AND PRACTICE OF NURSING 89 

ment and the opportunity, at the same time, to measure the 
amount still to be accomplished. 

3. A job analysis of the standards of work, attitudes, tastes 
and appreciations, and the qualities which make students pre- 
fer one service or one kind of work to another and which, in 
turn, are accentuated and developed, that is, learned by practice 
in that particular service or kind of work. For instance, there 
is a difference, more clearly felt than defined, in these various 
services, which makes some doctors specialize in one or the 
other; and, too, it is often possible to distinguish a medical doctor 
or physician from a surgeon, just as it is often thought possible 
to differentiate people in other callings. There is a difference 
in both the services and in the qualities of the people making the 
choice, and, in turn, each reacts upon the other, as cause upon 
effect, and vice versa. 

There is a difference in the very atmosphere of our medical 
and surgical wards, between these and an obstetrical ward, and 
between each of these and a children's ward. This atmosphere 
is created, in each case, by the different situations, conditions, 
treatments and activities, and by those who conduct these 
activities. 

All such differences are seen to have great potential significance 
in teaching and learning when we remember that all education is 
a process of growth and development (not only in knowledge and 
skills but in qualities of heart and mind) brought about by the 
constant adjustments we are obliged to make. Different condi- 
tions and situations require, and therefore demand and give 
practice in using, different qualities or rather possibly the same 
qualities, but in different degrees. These different demands, 
therefore, bring opportunities to teach and learn certain qualities 
and abilities as well as special knowledge and skills. For in- 
stance, in surgery we expect to teach, and the students to learn, 
about various operations and their treatment and to acquire 
skill in aseptic technique in assisting with dressings. In the same 
way, at the same time, and by the same method they should also 
learn especially such qualities as alertness, both mental and 



90 METHODS AND PRINCIPLES OF TEACHING 

physical, presence of mind, ability to make quick decisions, a 
general preparedness for the unexpected, good judgment, and a 
high degree of technical skill. In medicine, on the other hand, 
because of the often prolonged duration of the disease, the fre- 
quent obscurity or un-get-atableness of the cause, the small, slow 
returns from treatments, the scene moves more slowly, the 
tone is lower, often more sombre, and changes are not so rapid; 
here, therefore, one has to have infinite patience, to be thoughtful 
and reflective, to be very observant and sensitive to very slight 
changes or symptoms and signs; one has to be satisfied with slow, 
small returns, with success and hope deferred, to cope with dif- 
ficulties, often over a long period with seemingly little results; 
and one must have imagination, sympathy, knowledge, and skill 
in dealing with people and in making them happy and com- 
fortable, mentally and physically, in spite of the uncertainty 
and the frequently prolonged illness. 

Content of the Course Indicated as Inside 
THE Ward 

Someone once suggested as an inscription to be placed over the 
door of a new library: 'This is not the library; the library is 
inside." So, too, is the basic course in nursing given inside the 
wards and clinics. 

It would be extremely helpful if this truth, which we all feel, 
were clearly indicated to all — ^teachers, students, and doctors, 
— by posting in each ward and clinic, on a bulletin board 
kept for educational purposes, the heading Content of the 
Course in Surgery or Medicine, Etc., with the job analysis 
under the three major sub-headings mentioned. Students would 
then know why they were assigned to such a ward or clinic, what 
it is they have an opportunity and are expected to learn, how to 
plan and map out their work and study, and could themselves 
measure their ability, and the rate and amount of their achieve- 
ment and progress, in relation to their own ability and to the 
standard set by the group. 

Such an outline would indicate the headnurse and teaching 



PRINCIPLES AND PRACTICE OF NURSING 91 

supervisor's course or teaching program. With it she would have 
her list of students assigned to the course just as would any 
teacher in a classroom. 

In addition to a job analysis of the content of each course, 
the methods of teaching and learning (such as the assignment 
of patients, the use of case studies, experience records and con- 
ferences, etc.) should also be posted on the bulletin board so that 
the students might differentiate between content and method and 
see the relationships between them. 

Simple Job Analysis of Procedures. — This has previously 
been discussed in relation to classroom teaching. A complete 
record of the technique of all the procedures should be kept in 
each ward as part of the content of the course. Reference and 
text books related to the subject or service should also be 
available in the ward classroom. 

Content Based on a Job Analysis of the Needs of the Indi- 
vidual Patient; or A Scientific Case Study as a Basis for Treat- 
ment and Nursing Care. Emphasis has already been made to 
the need for such studies and an illustration has been given. 
Mention was also made under the Producer's Projects which 
will be further discussed under Methods of Teaching. Mention 
is made here because the facts and principles revealed and the 
resulting program form a definite part and contribution to the 
content of nursing. 

Sequence of the Topics or Services and Time Required in 
Each. The sequence of experience in the various services and 
the time to be spent by each student would, necessarily, like any 
other subject to be taught, depend upon the content of each 
course, the relative value of each, the ease or difficulty with which 
it is learned, and the capacity of the individual student. 

As the length of the whole basic professional course in nursing 
is limited to a definite period of from two to three years, our 
plan should also provide for a definite period to be spent by each 
student in the various services, the time spent in each, and the 
sequence of rotation from service to service to depend, not upon 
hasty planning or no planning, or upon chance or the force of 



92 METHODS AND PRINCIPLES OF TEACHING 

circumstances (barring illness, etc.), but upon the educational 
value of each and upon the relation one service bears to the 
other; that is, it is well to have the elemental (not elementary 
because it is fundamental and forms the foundation of nursing 
principles) or basic experiences precede an experience in which 
the knowledge or skill gained in the first can be transferred or 
used, adapted, or applied to advantage in the second. For in- 
stance, experience in a surgical ward usually precedes the oper- 
ating room, and it is also better and safer for both patient and 
nurse if the operating room (where attention can be concentrated 
on one patient in one room so the student can be closely super- 
vised) precedes the obstetrical and communicable disease 
experience, in both of which a thorough knowledge of aseptic 
technique, surgical or medical, is so necessary. Again, as pre- 
viously stated, it is desirable that students learn to observe, to 
understand, and to care for infants and young children in a 
general pediatric ward before being thrust into the responsibil- 
ities and the danger to herself and others in caring for children 
in a communicable disease ward. 

This same principle of planning a cycle or sequence of experi- 
ence and of assigning patients and duties based on the needs 
of the patients and the experience and ability of the students 
should be observed in each service. 

To plan implies an assurance of a certain degree of control 
over the future; otherwise — if we know or believe we have no 
such control and that the future is entirely controlled and ar- 
ranged for us by someone else — it is useless to attempt to shape 
the future for ourselves or others ; therefore we have no responsi- 
bility for what may or may not happen. Herein, it would seem, 
lies one of the greatest drawbacks in our school system, in that 
the headnurse instructors in the wards, where the opportunities 
for teaching and learning are so great, frequently know little of 
what is being planned; that is, they seldom know much in ad- 
vance which students are coming to them, when they are coming, 
what their background of education and experience has been, 
their weaknesses and strengths, in what they need most help 



PRINCIPLES AND PRACTICE OF NURSING 93 

and guidance, or how long they will remain with them to be 
taught. 

Such uncertainty as to the past, present, and future, will usually 
dampen any interest or enthusiasm on the part of a headnurse 
for planning the experience or teaching of students. This un- 
certainty does not develop in either teacher or students a sense 
of responsibility, initiative, foresight, executive ability, or any of 
those factors in self-direction which enable people to help them- 
selves. Why should she be interested in teaching and planning? 
Why should she take thought for the morrow of a student who 
may not be with her on the morrow? Sufficient unto the day is 
her only security and will probably be her thought (conscious 
or sub- conscious) in planning. 

The headnurse, because of her position, her close contact 
with the students, and her control of their experience, occupies a 
strategic position which, it would seem, should be recognized and 
utilized in the whole teaching program. 

Time Spent in Each Service. — It has been indicated that 
our plan should provide that each student spend a definite period 
in each service, the time spent to depend upon the educational 
value of each. The question immediately arises — ^what is the 
educational value of each? 

It is fairly safe to say that, at present, no one can answer 
this question satisfactorily because there has never been a scien- 
tific study made of the content which should be covered, or how 
long it would take to cover it. That is, we have no classified 
analysis of cases cared for by students in our medical or surgical 
wards, etc., or of the treatments given, by means of which any 
comparison might be made from month to month in any one 
hospital or between different hospitals. Two months at one 
season or in one hospital might be equivalent to three months 
at another season or in another hospital. 

We cannot, therefore, accurately evaluate any two, three, or 
four months' experience so can only express an opinion (and 
opinions vary greatly) as to how long this experience should be. 
We approach a sound basis more closely in the obstetrical ex- 



94 METHODS AND PRINCIPLES OF TEACHING 

perience when the requirements state that a student should have 
assisted with or deUvered a certain number of patients. The 
same is sometimes true of the operating room. 

It seems quite clear, with even a superficial glance at the 
problem, that to give our students, even in the same hospital, 
equal opportunities, records should be kept whereby the students' 
experience in terms of patients (or cases) cared for might be 
evaluated and reshaped in so far as our control of conditions 
make possible. 

This problem of planning the experience of the students in 
advance and sharing this plan with all those concerned, while a 
very difficult one to solve, is by no means an impossible one, and 
the results will well repay any amount of time, effort, and 
patience involved. 

Services Included in Experience. — In addition to the usual 
services offered — medicine, surgery, obstetrics, and pediatrics — 
every effort should be made to provide experience in the care of 
mental disease, diseases of the eye, ear, nose, and throat (so 
serious in their complications and so commonly met with in 
home, school, and in all forms of public health nursing) ; and 
in some form of community health nursing. The out-patient de- 
partment or dispensary offers a rich vein of experience which we 
have only begun to tap. We are missing a great opportunity 
for teaching the prevention of disease, the watchword of modern 
medicine and nursing, if our students do not have experience in 
the various clinics (supervised by workers who have a keen ap- 
preciation of the social and economic aspects of disease and 
methods of prevention) as part of their general nursing experience 
in medicine, surgery, pediatrics, obstetrics, and mental and 
nervous diseases. 



SECTION V 
METHODS OF TEACHING 

The methods of teaching used in the ward, or any part of 
the field of experience, should, like those in the classroom, be 
based upon and governed by the Laws of Learning — Readiness, 
Mind-set, or Purpose; Law of Effect — Satisfaction (success) or 
Annoyance (failure) ; Law of Exercise, Recency, Intensity, and 
the Law of Association. 

Mind-Set or Purpose — Service to Patients. — Our first 
thought is that there are patients to be cared for whom we desire 
to serve; the patient, and his needs as an individual, will be at 
all times the centre of our thought and study. 

This service to a patient or patients will consist of purposeful 
activities carried to completion in their natural setting. As pre- 
viously stated, bound up with this service, not apart but insep- 
arable from it, there is a content in terms of ideals, attitudes, 
appreciations, standards, knowledge, and skills which our stu- 
dents should learn by doing and serving. We cannot emphasize 
too much the fact that there is no other way of becoming a good 
nurse except by doing intelligent, skilled nursing in the spirit 
of service. The more good nursing one does, the better nurse 
one becomes. It is like the parable of the ten talents in the 
Bible ; the talents which were put out to good use were not only 
doubled, but the one who made good use of his talents was richly 
rewarded with wider and greater opportunities and responsibil- 
ities, and with capacity to enjoy them. To the one who failed to 
use his talent, the talent, itself, was taken away and the man was 
punished with failure and the loss of the opportunity to use even 
the talent he had. 

An interesting aspect in relation to this parable is the basis 
of reward; in each case the reward is based upon achievement 

95 



96 METHODS AND PRINCIPLES OF TEACHING 

in relation to individual capacity, in that the same reward is 
granted to the man who doubled his two talents as to the one who 
doubled his five talents. 

Our standards and what we do, the student's standards and 
what she actually does, and the way in which she does it (the 
accompanying thought, feeling and appreciation) determines 
whether she is learning to be a good nurse or a poor nurse. Our 
problem is to keep these factors constantly before us; to think 
of and develop each ward or dispensary clinic, etc., as a special 
and essential aspect of a course in nursing — ^the headnurse and 
teaching supervisor the teachers who plan their course both in 
content and method guided by the same aims and principles as 
those laid down for her sister instructor in the classroom. It is 
desirable that the teachers in the wards share, to some extent at 
least, in the teaching in the classroom for many reasons — ^to 
break down the wall or barrier between the classroom and the 
wards, between theory and practice, and the attitude of mind 
toward the ward as a place to work in rather than to teach and 
learn in. This co-operation also insures uniformity of teaching 
and that the teachers will be available to help the students to 
recognize and solve difficulties and problems as they arise. 

Mind-Set or Purpose — Spirit, Ideals, and Method of Science. 
— To develop this mind-set, which is stated as one of the aims 
of the course, perhaps it would be well to compare nursing with 
one of the recognized sciences. 

Science, to quote from Havelock Ellis (who in turn quotes 
from Dr. Charles Singer, one of the most noted historians of 
science) on the "Art of Thinking," is defined, "no longer as a 
body of organized knowledge, but as 'the process which makes 
knowledge,' as 'knowledge in the making'; that is to say, the 
growing edge between the unknown and the known. As soon 
as we thus regard it, as a making process, it becomes one 
with art." 

Nursing is accepted generally as an art but not so generally 
as a science. To discuss this distinction is not the purpose of 
the present pamphlet, but to urge that at least we profit by th ""■ 



PRINCIPLES AND PRACTICE OF NURSING 97 

lessons which science, in its spirit, ideals, and methods has to 
teach. This is one of the great lessons of the age in which we live. 

When we compare our course in nursing with a course in 
science, such as chemistry or anatomy, we find that, while they 
differ widely in many aspects, yet they are alike in that each con- 
sists of lectures, recitations, demonstrations, and of laboratory 
experience if we (with caution and reservations) for convenience 
and for what is revealed, speak of our wards and clinics, as 
laboratories. 

An instructor in chemistry will plan the laboratory experience 
with the same care and detail as her classroom lectures and reci- 
tations. We should plan it with even greater care and detail 
both for the safety and comfort of our patients and because, as 
stated previously, the ward experience is the most vital, most 
rich in knowledge and opportunities for teaching and learning. 

When we analyze our wards or dispensary clinics as fields for 
teaching and learning and compare them with a science labora- 
tory, it is apparent that we have many advantages from an 
educational point of view, advantages much sought after in 
modern education, not only by teachers in science but by teachers 
in mathematics, geography, history, and literature. 

This is because in the very nature of our work or experience 
are inherent those factors, summed up in the term projects, most 
conducive to learning, to the development of character and per- 
sonality. To the would-be nurse, prompted by the desire to 
serve, not only is the whole course a project or series of projects 
but in this respect, there need be no break except in time and 
place, between her present experience as a student and her future 
experience as a graduate; the one is the natural outgrowth and 
development of the other, a continuation of learning and growth. 

This fact has great potential value in teaching and learning; 
its significance should be fully appreciated and utilized by both 
teacher and pupils. 

Further analysis and comparison of our laboratories and a 
science laboratory, reveal the following contrasts and similarities, 
all of which suggest opportunities for teaching and learning: 



98 METHODS AND PRINCIPLES OF TEACHING 

.1. In both we have facilities for teaching — well-lighted, well-ven- 
tilated, attractive rooms with equipment and illustrative material 
for teaching. 2. In both we have students and a teacher or 
teachers. In the nursing laboratory the teacher is the head 
nurse with the collaboration of the teaching supervisor and 
specialists, such as, doctor, social service worker, metabolism and 
nutrition worker, mental hygienist, occupational therapist, den- 
tal hygienist, and physiotherapist. 3. In both, the students 
learn by doing, the amount learned depending upon the purpose- 
fulness of the activities, the continuity of experiences, and the 
amount of thought given to them. 4. In both, the teaching is 
less formal than in the classroom and there is the advantage of 
the direct contact of mind to mind, and of individual or small 
group teaching. There is also the great advantage in a nursing 
laboratory of being able to assign duties according to the needs, 
the individual capacities, and the degree of knowledge and skill 
of the learner. The students can also be measured in an all- 
round way and according to their achievements in relation to 
their individual abilities. They thus feel their mark to be fairer, 
more just, than in the classroom. 5. In both we have groups 
working together, but in the nursing laboratory we are apt to 
have a more highly socialized group, not only because we know 
the learning process and future needs make this desirable, but 
because, in addition, the present successful completion of the 
work in the wards demands it. In a science laboratory, as a 
rule, each student carries out his own experiment unrelated 
(while it may be the same) or uninfluenced by the success or 
failure of the others. He does not have that sense, at least in 
as natural or real a way, of sharing and co-operating in activities 
having a common purpose and each contributing to the success 
of the whole. Herein lies our opportunity to develop those social 
qualities of character and personality previously mentioned 
under aims and ideals. 6. In a nursing laboratory, the students 
are prompted by an altruistic spirit of service to the patient, the 
desire of learning knowledge and skill being secondary, often 
unconscious and requiring stimulation. 7. In a science labora- 



PRINCIPLES AND PRACTICE OF NURSING 99 

toiy the student's purpose, if he has one, is to use the knowledge 
or skill for his own ends. Frequently, however, he has no aim 
and no immediate use for the knowledge, and his idea of its fu- 
ture use is too vague and remote to supply incentive or motive 
in learning. 

In nursing, every time a student nurse performs a service 
intelligently, successfully, she is being a good nurse, and to that 
extent is constantly achieving her goal, and should have all the 
satisfaction of doing so. The tremendous possibilities of this 
we realize when we recall the 'Xaw of Effect" in learning. 

8. In a science laboratory, experiments or procedures are not 
repeated until perfected, because skill, although necessary, is 
not a prime objective. In nursing it is essential, and provision 
in teaching must be made for acquiring it. This has been dis- 
cussed under the Law of Exercise. 9. In both, there is a definite 
content to be learned for present and future use. The content 
in a ward, has already been outlined. 10. In both a nursing 
and science laboratory, the scientific method of work or study 
is equally applicable. In our ward, however, although our stu- 
dents, by their accurate observations, careful records, and nurs- 
ing care, share daily in using this method, they, as a rule, are 
totally unconscious of the steps taken as being part of a method. 
All too frequently, neither in the wards nor when studying any 
of the sciences in the laboratories, where they either use or see 
demonstrated all the steps in the process, is this method explained 
as method. Its significance, the thrilling story of what its use has 
achieved in the progress of medicine, of science itself, and other 
fields of learning, and its application to our own field have, in a 
large measure, been ignored. We ourselves, quite naturally and 
in the midst of almost insurmountable difl&culties, have, perhaps 
unavoidably, tended to completely ignore it; and yet, so uni- 
versal is its use and appHcation, so free does it make us as inde- 
pendent workers, capable of solving our own problems, that an 
instructor, doing a piece of research work in physiological chem- 
istry covering a period of a year, when asked, ''What do you 
consider has been of greatest and most lasting value to yourself 



100 METHODS AND PRINCIPLES OF TEACHING 

from this year's work in research?" unhesitatingly replied, "A 
method of work," adding that no matter what she might want to 
study in future she would know how to go about it so as to 
obtain results scientifically accurate and with the greatest 
economy of time, energy, and money. (An illustration of this 
method in a more closely related field is that of a doctor in 
making a diagnosis.) 

We feel, therefore, that to have our students grasp the spirit 
of science, the significance of its achievements; to give them some 
freedom, through practice, in the use of scientific methods, with 
all that is implied in clearness and accuracy of thought and state- 
ment, will be one of the greatest, most lasting and far-reaching 
benefits to them. It must be understood that nothing which is 
said here or elsewhere is in the light of criticism or lack of appre- 
ciation. On the contrary, the writer, when discouraged, has only 
to reflect upon the present and past achievements of our splendid 
nurses to be stimulated and inspired by their example. We are 
now, however, entering upon a new era in nursing, and it is this 
sense and spirit of progress which gives us courage and hope 
for the future. 11. Between a nursing laboratory and a science 
laboratory, there is a striking difference in our observations or 
experiments, in that, in the first we are trying to save the lives 
of the human beings under treatment; whereas in the second, we 
deal mostly with inanimate things or with animals, not for the 
purpose of saving their lives (which, however, may be highly 
valued and protected) but for saving the lives of future 
human beings. 

In a science laboratory each thing that is done is more or less, 
frankly, an experiment to find out or to prove something in which 
the result may or may not be of benefit to the animal. The 
product may be thrown away as of no value — ^what the student 
learns only is of prime value. 

In nursing, on the other hand, we do nothing that we are 
not reasonably sure will be of benefit to the patient. Each feel- 
ing, thought, or act of the nurse is of more or less vital im- 
portance because it plays a constructive part in the curative or 



PRINCIPLES AND PRACTICE OF NURSING 101 

preventive health program. The purpose is service — ^what the 
student learns has most value when it brings, at the same time, 
the satisfaction of contributing to the welfare of the patient. 

Service to the Patient as an Individual, the Unit or Centre 
of Thought and Practice. — There are two methods, commonly 
used in our wards, of regulating the service rendered to patients 
and the experience of the students; one is rightly called the 
Efficiency Method, the emphasis usually being on training, and 
the economy of time and energy in accomplishing the work 
which has to be done. In this method the patient is not the 
unit or centre of thought. But the work to be done is classified 
into, beds to be made, baths to be given, temperatures to be 
taken, treatments to be given, diets to be prepared and served, 
medications to be given, charting to be done, dressings to be done, 
etc. The thing to be done is the unit and centre of thought and 
endeavour. This does not mean to suggest that, when this method 
is used, thought is not given the patient, but that the emphasis, 
in the minds of young, inexperienced students, tends to be largely 
on the thing to be done. 

The second method is that of making the patient the unit 
or centre of thought, the student's whole endeavour being to 
render the best possible service based on his individual needs. 
It is sometimes called the Case Study Method but the term is 
used here rather reluctantly because of its possible misuse and 
misinterpretation, the emphasis being on the case and not the 
patient, and on the study and not the service. 

In this method, two, three, or four patients are assigned to each 
student, the number depending upon their condition, and the 
student's experience, ability, and opportunity to give them ade- 
quate care. The student is made entirely responsible for these 
patients (as far as their safety and comfort will permit) during 
the hours assigned. During the hours when the student is not 
on duty, these patients are assigned to a second student, the first, 
however, following with interest and concern the patient's wel- 
fare throughout. Such treatments required by the patients, if 
not already learned, are taught as the need arises providing they 



102 METHODS AND PRINCIPLES OF TEACHING 

are not too diffiicult to be understood and carried out by the 
student in accord with given standards. 

The following outline indicates a method of assigning patients: 
It represents the patients, etc., assigned to a group of students 
during a week of their experience on a male medical ward. The 
spaces crossed indicate that the students were off duty for 
the day. 

It may be mentioned here that this method, as outlined, and 
the same form have also been used with marked success over a 
considerable period of time in wards staffed almost entirely by 
graduate nurses, where the emphasis is not on the education of 
students but only on the care of the patients and the efficient 
management of the ward. It is stated by headnurses and gradu- 
ates on general duty, or group nursing, that the method insures 
a more interesting, a more varied, and a more even distribution 
or assignment of the patients so that all are cared for and all 
the nurses complete their work about the same time. The method 
is, therefore, found to be an efficient method. Other advantages 
are stated in the following paragraphs: 

Length of Time Patients are Assigned. — The length of time 
a patient will be assigned to any one student demands very care- 
ful thought both from the standpoint of the patient and the edu- 
cational needs of the student. No set time can be given as the 
needs of each patient and each student will vary more or less. 
To change too frequently is to ignore the needs and to destroy 
the benefits of this method to both patient and student. On the 
other hand, it is important that every effort be made to assign 
the patients and to regulate the student's hours of assignment to 
give her a rich and varied experience. This careful planning 
and teaching are only possible when the headnurse knows how 
long she may expect the students to remain with her. 

Advantages and Disadvantages of Above Methods. — That 
both methods have advantages is true; that by both methods 
good nursing may be assured, and that both may develop good 
nurses, the excellent work done under both methods, and the 
.many excellent nurses trained testify. 



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PRINCIPLES AND PRACTICE OF NURSING 107 

The question is, which tends to insure the highest quality of 
service, which insures a more thorough understanding of the 
patient's needs, which is more likely to meet the students' present 
and future needs, and which is more likely to develop the habits 
of thought, feeling, and conduct, as well as knowledge and skill, 
which we deem desirable and necessary? 

The writer has had a fairly long and wide personal experience, 
as a student and as a graduate, and has talked with many stu- 
dents and graduates of the advantages and disadvantages of each 
method, so speaks from experience. However, the remarks which 
follow are admittedly too sweeping and are meant not to cast 
reflection upon the quality of work or the product, but to 
stimulate thought and discussion of the methods themselves. 

The advantages of the Efficiency Method have been indicated. 
Probably a judicious use of this method is necessary in order 
to give sufficient practice in certain procedures to develop speed, 
precision, and skill based upon the Law of Exercise and Recency 
of use, etc. It is possible, too, by this method to develop a body 
of knowledge and principles about such subjects as the cardinal 
symptoms, temperature, pulse, and respiration, or the various 
types and stages of wounds and their treatments, because it 
means contacts and facts learned about a great number and 
a great variety of patients and diseased conditions, and also with 
many phases of disease. It gives an extensive rather than an 
intensive experience. 

Perhaps more important still is the opportunity for making 
comparisons and noting contrasts which are often striking and 
which reveal facts which would otherwise be unobserved. For, 
instance, when a student is taking and recording in a book the 
cardinal symptoms of all the patients in a ward, the impression 
of the pulse and temperature, etc., of the first patient is fresh 
in her mind when taking that of the second, and that of the 
first and second when taking that of the third, and so on, each 
throwing the other into relief as black against white, so that each 
is observed more clearly and distinctly because of the other. It 
is possible, too, to build up associations; for instance, to associate 



108 METHODS AND PRINCIPLES OF TEACHING 

a high tension pulse with nephritis, if there are several cases 
in the ward. 

While all this is possible, it is not very probable if the emphasis 
is on taking the pulse, etc., — the thing to be done and on getting 
it done. The facts learned will relate chiefly to the thing done 
and the mechanics of doing it. This method, therefore, in spite 
of its advantages, is apt to have all the faults of mass production 
— quantity at the expense of quality, skill at the expense of 
knowledge and understanding of the patient, and appreciation 
of his condition and his needs. 

Advantages of Second Method — The Patient as a Unit the 
Centre of Thought. — This method, in the opinion of the writer, 
has many advantages for both patient and student; also for the 
headnurse who is responsible for the patients, and for the 
smooth running of the ward. 

Effect on the Patient, — As regards the patient, we have only 
to imagine ourselves (and this imagination is something for stu- 
dents to cultivate) in his place, to appreciate the ease of mind, 
confidence, and relaxation of mind and body which comes from 
knowing that the person caring for you understands your needs, 
and is competent to do all that may be required. That feeling 
of uncertainty, anxiety, and even fear and shrinking which often 
comes to a sick person, already shaken and fearful, every time a 
strange or different nurse approaches him, may act as a slight 
shock and, when frequently repeated, may have a cumulative 
effect having, to some degree at least, the harmful effect of the 
anxiety and doubt accompanying an operation. Patients often 
cry when nurses are changed, and this is often the sole reason 
given by a patient for desiring a special nurse. 

We have only to note the attitude of children, who have less 
control and fewer inhibitions, so show their feelings more, to 
realize this; and most of us, — even in materialistic matters 
(where nothing vital, or even very important, but only better 
service with less bother, is at stake), such as having our nails 
manicured, our hair shampooed, buying hats and shoes and even 
trifles, — ^prefer and even insist upon having the same person 



I 



PRINCIPLES AND PRACTICE OF NURSING 109 

"wait on" us; and when ill, to have your breakfast served by 
one person, your temperature taken by another, your bath or 
medicine or treatment given by another, and so on, is most dis- 
tressing, as anyone knows who has been ill. Is there not a 
danger that the patient will feel that she is a bath to one, a 
temperature to another, a dose of medicine to another, and to 
no one of them a human being whose needs, spiritual, mental, 
physical, or social are all comprehended by anyone? 

To illustrate by quoting from a paper previously written: 
''Our text books, our methods of teaching, the method and char- 
acter of our supervision in the wards have all tended to stress 
the mechanical, routine aspects of nursing rather than the vital, 
human, and educational side. The student is, therefore, apt to 
think not so much of the patient and his needs but of her needs, 
that is, of what she has to do, and how she is going to do it and 
get it done on time. The writer once heard two students on 
their way to class discussing their morning's work. One said, 
'I had a perfectly dreadful morning; I had ten beds to make.' 
The other agreed that that was 'perfectly dreadful' and wondered 
how she ever got through with ten beds to make. I wondered why 
this nurse should have ten empty beds to make and, if so, why 
she considered it so dreadful, so I stopped to inquire if she meant 
empty beds. She said, 'No! Patients in them! I thought I'd 
never get through.' " 

The last thought is not an unnatural one, with ten patients 
to care for, but the whole thought seemed to be related to the 
beds to be made and not concern for the inadequate care and 
consideration which the patients must have received. 

Effect on the Student. — For the student, assigning a patient 
to her care instead of a treatment, etc., means that she should 
see each patient as a whole, in true perspective, as a member of a 
family and the community, and, as it were, in all his dimensions. 
When assignments are made in the form of treatments to be 
given, the student's understanding of the patient and his needs, 
and her expression of the art of nursing are apt to be just as 
incomplete and undeveloped as Egyptian art in which one sees 



110 MEIHODS AND PRINCIPLES OF TEACHING 

people represented in the flat, in two dimensions only, and, in 
distorted, unnatural positions — part of the body, and even part 
of the head being in profile while part is in front view. Where 
the complete care of a patient is assigned, the student's under- 
standing and her expression of the art of nursing should be more 
comparable to Greek art in which one sees people represented 
in the round, perfect in its expression of all the feelings, thoughts, 
desires, emotions, and actions which go to make up the complex 
human being in all his complex human relationships. The result- 
ing conception of nursing and the opportunity given for attaining 
the perfection of art should be very far-reaching in its 
implication and effect. 

It would seem that any system used exclusively or to such an 
extent as to break up, by specialization (as outlined under the 
efl&ciency method), this unity of thought, and conception of the 
patient (however efficient it may be from the standpoint of get- 
ting the work done) , would tend to rob the experience of much of 
the feeling of service and of much of its educational value. 

Is there not danger, by the exclusive use of such a system, 
of giving an incomplete and distorted picture of the disease and 
its treatment? Does it not tend to direct the student's attention 
to the treatment and technique rather than to the patient and his 
needs? Does it not tend to rob nursing of much that is finest 
in its art? For, just as specialization of labor in industry has 
reduced it to a series of isolated, mechanical processes, is there 
not danger that specialized assignments of treatments, etc., may 
become unrelated, unintelligible, uninteresting tasks to student 
nurses? While many of us trained, and owe much to our train- 
ing under the efficiency system, most of us would agree that, from 
the standpoint of developing artists and the love of an artist for 
his work, there are many disadvantages in its exclusive use. 

Effect on the Administration. — This specialization, called the 
efficiency method, besides the possible disastrous effect on the 
education of the student, is often one of the most common sources 
of complaints, of misunderstandings, discomfort, and unhappiness 
to patients in our hospitals. As previously stated, it often forces 



PRINCIPLES AND PRACTICE OF NURSING 111 

very sick people, who can ill afford it, to have special nurses. 
This adds to their trouble and mental anxiety and also lessens 
the opportunity of experience for our students. 

When all the needs of the patient as a member of his family 
and the community are really considered, we are likely to have 
happy, well-cared-for patients, appreciative, grateful relatives 
and friends, and students learning to be intelligent, skilled, sym- 
pathetic nurses, ready to serve as responsible workers in the 
Community Health Program. This means that the hospital 
is fulfilling two of its most important functions in its role of 
a Community Health Centre. 

System or Method Merely a Tool. — It should be remembered, 
however, in considering the advantages and disadvantages of 
any method or system, that, just as a river cannot rise above 
its source, neither can any system rise above the people who 
initiate and develop it. The system is only a tool, a means to 
an end. In the hands of a skilled teacher a poor system may 
develop good nurses, whereas a good system in unskilled hands 
may develop poor nurses. 

The Use of Assignments and a Scientific Method of Study 
in the Wards. — We have said that our knowledge of nursing 
care is too vague and general, a sort of blanket treatment, not 
developed and outlined according to the needs of the individual 
patient. For instance, the treatment prescribed by a doctor 
varies greatly according to the diagnosis, symptoms, and indi- 
vidual differences, etc. Not only is the treatment for cardiac 
patients different from that for, let us say, hyperthyroidism, but 
it differs for different cardiac patients and also for different 
stages of the disease. 

So far from this careful study and differentiation is, on the 
whole, our present knowledge and practice in nursing, that a stu- 
dent can, and, in some hospitals sometimes does, give nursing 
care to the patients on one whole side of a ward, without even 
knowing the diagnoses, or knowing this, is conscious of little 
more. We are held responsible for the nursing care — should we 
not prescribe nursing care for each patient as doctors prescribe 



112 METHODS AND PRINCIPLES Ot' TEACHING 

medical care? To prescribe simply means "to write before'^ or 
"to designate in writing," and nursing care, or the care a 
nurse is expected by the hospital, doctors, and public to give, 
includes, not only carrying out faithfully and skillfully what the 
doctor has prescribed, but often much more; so much more 
sometimes, as in typhoid or pneumonia, or in the care of infants, 
that a doctor will say "his life will depend upon the nursing care 
he receives." 

If there is anything curative in personal hygiene, — ^in mental 
and physical rest and comfort, diversion, and occupation; in a 
feeling of cleanliness, in a mouth sweet and clean; in hair clean, 
well brushed, free from pediculi; in food well selected, in proper 
amounts, attractively served at the proper time and under 
proper conditions; if there is anything curative in the effect of 
plenty of water to drink; in the formation of proper habits of 
elimination ; in the habits of sleep, play, and general behaviour of 
children; in the selection of a rubber ring for this patient, a 
book for another, extra pillows for another, a hot-water bag for 
another, the bed protected with pillows for another, an air mat- 
tress for another, a cradle for another, and all the manifold 
things which a nurse may do to bring comfort of mind and body 
to the patient — ^then there is much for a nurse to prescribe which 
is not prescribed by a doctor. 

There is a doctor's "order book" but not a nurse's "order book" 
in the ward; nowhere, in most hospitals, at least, is written the 
prescribed nursing care. Any directions given are usually oral 
and we know how subject to error and neglect these are — for this 
reason we usually insist upon written instructions from the 
doctor. Let me tell you an incident to illustrate this need. 

One morning when going to visit a student nurse ill with diph- 
theria, I met a student nurse just leaving the room, who, when 
asked about the patient's condition, said: "Oh! She is better 
to-day; she is taking her own bath." This meant that neither 
nurse knew the danger such exertion incurred. When the situa- 
tion was mentioned to the headnurse, she was shocked, and said, 
that while directions for nursing care or for avoiding exertion 



PRINCIPLES AND PRACTICE OF NURSING 113 

were not written anywhere, both nurses, although they were stu- 
dents, "should have known better" — just how or why was not 
clear. Was this insuring good nursing care for the patient, or 
learning to be a good nurse by experience for the student? And 
is the avoidance of exertion in this case not of sufficient import- 
ance to be prescribed in writing? Not so very long ago this 
would have been prescribed by the doctor just as many other 
things, formerly considered medical, are now considered nursing 
treatment. 

Study of Needs to Precede Nursing Care. — In the classroom 
it is customary to give assignments out of a book for study, in 
order that the students may gain knowledge for some future use 
in caring for some unknown patient. And yet in the ward, where 
the student has immediate need and, therefore, an interest and 
motive for acquiring such knowledge we, as a rule, fail to make 
any assignment except in terms of work to be done in the present 
or immediate future. By this failure we miss our greatest oppor- 
tunity for teaching, and the student for learning. Can a student 
understand a patient's needs as an individual? Can she, a 
stranger unintroduced, make a satisfactory immediate contact? 
And can she readily form any broader conception of nursing than 
that of doing more or less mechanical routine procedures, if 
she is not expected to, and does not read his history, study the 
diseased condition and the treatment prescribed by the doctor, 
make her own observations of his needs, and formulate a plan 
of nursing care based upon this study? Without this study and 
formulation of a plan (formulated by the student in so far as 
her knowledge will permit but carefully supervised by the head- 
nurse) would the care of the patient be a project, a purposeful 
activity? To make it a project, when a new patient is to be 
assigned, should the assignment not be made on the preceding 
day and references and suggestions be given the student as to 
how to make her study in a scientific way? 

Method of Assigning Patients. — The patients should be as- 
signed by the headnurse after conferring with the teaching 
supervisor. A choice of patients made by a student with reasons 



114 METHODS AND PRINCIPLES OF TEACHING 

satisfactory to the headnurse should receive consideration. 
Emphasis should be placed not on the medical problem, except 
as it relates to nursing, but on the nursing problem, the two 
together meeting all the need3 of the patient. 

As stated previously the special nursing problem to solve may 
relate to various aspects, mental or physical, family or social; 
or there may be no special reason for assigning a particular 
patient except that he or she requires care. The student should 
understand that this, in itself, is sufficient justification to warrant 
her most thoughtful care and attention. Whether or not it may 
be deemed necessary for the student to continue actual nursing 
care beyond a certain period, she should continue to study and 
follow his progress with interest and concern. 

It may be mentioned here that if the ward or clinic is to be 
a classroom to teach and learn in, there should be text and 
reference books readily available for study and guidance. There 
should also be available a quiet room or space for reading and 
writing and for teaching or confe-rences. 

Treatment Cards Attached to Chart. — The value and the 
pressing demand for cumulative information in writing relating 
to nursing has already been emphasized. The need for a written 
program of nursing care for each patient has also been em- 
phasized. There is no doubt that a system which requires a 
definite formulation, in black and white, of the nursing care we 
propose to give (based on such studies already indicated) will 
greatly improve the character and quality of our work, and, 
therefore, the care of our patients, and the education of our stu- 
dents. It will tend to stimulate and develop in ourselves and in 
our students more thought and imagination, a greater degree of 
accuracy and precision, keener observation and an interpretation 
of the significance and relationships of facts, and a more con- 
scious effort on our part to build up the ideals, knowledge, and 
standards of the nursing profession. 

A system which is being tried with increasing success, is to 
'attcch to the chart a card on which is recorded under Medical 



PRINCIPLES AND PRACTICE OF NURSING 115 

Treatment, the treatment prescribed by the doctor; and under 
Nursing Treatment, the care prescribed by the headnurce or 
supervisor. These cards are increasingly popular and in de- 
mand with the medical staff, and in some wards are found indis- 
pensable. In addition, they tend to inspire confidence in the 
amount and quality of nmrsing care given and should gradually 
and soundly build up a conception of niu-sing as having a con- 
tent and method of its own, a sister profession working side by 
side with the medical profession, with a common purpose of 
service in the prevention and cure of disease, and, to that end, 
the education of student doctors and nurses. 

TREATMENT 

Name . Age Ward 

Medical Treatment Nursing Treatment in Relation To 

1. Cardinal Symptoms: 1. Medical Treatment Prescribed: 

2. Diet: 2. Safety and Comfort, Mental and 

Physical : 

3. Eliminations: 3. Hygiene and Health Habits: 

4. Medications: 4. Social Needs: 

5. Special Treatments: 5. Instruction: 

Note. — Diagnosis on reverse side. Spacing on card may be arranged to 
allow written directions mider suitable headings. 

Each card would be made out by the student, responsible for 
the patient, after submitting her plan, for approval, to the head 
nurse. The size and shape of the card would necessarily be 
adapted to the special charts used. On the reverse side would 
be the patient's name, diagnosis, and special remarks. 

From the administrative as well as the educational standpoint, 
the use of such cards has many immediate advantages. Mis- 
takes, neglect, treatments omitted, or treatments continued when 
no longer needed, are quickly brought to one's attention. The 
card gives a complete picture of the treatments prescribed, and 
forms a varied content of correlated knowledge — ^the reason why 
for each treatment or medicine, etc., — for an individual lesson 
or case study. 



116 METHODS AND PRINCIPLES OF TEACHING 

Such information has permanent as well as immediate value. 
When the patient is discharged, or when new cards are written, 
the cards may be filed under a classification of diseases. By such 
a method, we collect not only a mass of information about nurs- 
ing in specific cases, and about nursing in general, but we have 
organized knowledge in a form which permits us to go back and 
check up our work, to note progress made in content and method, 
to compare facts presented by the study of a great many cases 
of the same class, and of different classes, and to select facts 
common to all cases of the same class ; in other words, to formu- 
late principles, to organize knowledge — ^the process of making 
knowledge, which is science. 

Case Studies and Experience Records in Teaching 
AND Learning 

The value of case studies as the basis of diagnosis and treat- 
ment lias been fully demonstrated and accepted in law, medicine, 
and social case work; and in our own profession there is a 
growing interest and appreciation of their use and value. In 
fact, more and more we are coming to recognize that the methods 
and aims are and should be essentially the same in all types of 
service, the case study method being the common denominator. 
Also, as previously stated, we are coming more and more to be- 
lieve that there should be no sharp line drawn between the 
hospital and the community. A man is still a member of his 
family and of the community — "No man liveth unto himself" — 
whether he be at his work, in his home, or a patient in the hos- 
pital. So that, in providing for the patient's needs, just as we 
recognize that you cannot separate mind from body, or vice 
versa, neither can you separate the family, or the social needs 
and relationships. A nurse is equally a public health and social 
service r/orker whether she cares for a patient in the hospital 
or in his home and whether she cares for one patient or more 
than one in the community. 

The following outline is suggested as a guide to the students 
in making their case studies. 



I 



PRINCIPLES AND PRACTICE OF NURSING 117 

Outline of Case Study. 
I. History. 

(a) Social — as far as it bears on medical and nursing care. 

1. Source — referred by? 

2. Age — Nativity — Citizenship? 

3. Occupation — Is it related to the health problem? 

4. Family responsibilities — number of children; maxi- 

mum and minimum age of children. 

5. Standards of living — neighborhood; home conditions, 

number of rooms, etc. ; sanitation. 

6. The family problem due to sickness. 

7. Known to Agencies — Out-Patient Department, and 

the Agencies' present plan of treatment. 

(b) Health Habits. 

1. Mental outlook, use of leisure, interests, or hobbies, 

etc. 

2. Cleanliness — care of teeth, hair, nails, bathing, etc. 

3. Dietary — appetite, condition of teeth, weight; num- 

ber of meals; types of food, likes and dislikes; 
fluids, water, tea, coffee. 

4. Sleep and rest. 

5. Exercise and fresh air. 

6. Eliminations — regularity. 

7. Child habits — daily regime, rising, going to bed, rest, 

play, bathing, meals, etc. Bed wetting, night ter- 
rors, nail biting, thumb sucking, sleep walking, tics, 
masturbation, social behaviour. For suggested 
study of behaviour use nursery school form. 

(c) Medical History. 

Past. 

Present — including duration of disease, etc. (May in- 
clude complications and sequelae.) 

II. Symptoms, physical signs and diagnostic measures. 

1. Subjective. 

2. Objective. 

3. Results of examination — ^X-ray, laboratory reports, 

etc. 

III. Diagnosis. 

(a) Social diagnosis, that is, what the immediate problem 

seems to be. 

(b) Medical diagnosis. 



118 METHODS AND PRINCIPLES OF TEACHING 

IV. Treatment and Nursing Care. 

(a) Medical — Doctor's orders regarding: 

1. Rest, diet, nutrition, eliminations. 

2. Surgical measures: major, minor. 

3. Physiotherapy. 

4. Medications. 

5. Special treatments. 

(b) Nursing in relation to: 

1. Social needs — arrangements for care of home, of 

family, of children, friends, position, or work, etc. 

2. Medical needs — observation and recording of symp- 

toms relating to medical diagnosis, results of 
treatments, patient's condition, etc. 

3. Health habits — see outline above — including occu- 

pational therapy. 

4. Providing suitable environment — fresh air, proper 

temperature, quiet, order, cleanliness, general 
attractiveness. 

5. Instruction in health habits, etc., including preven- 

tive measures. 

V. Progress and Prognosis. (May include complications and 
sequelae.) 

VI. Discharge and ^'Follow Up'' — items as: 

1. Instruction given relating to treatment and pre- 

vention. 

2. Return to home — work — ^rest — school — treatment 

and prevention. 

3. Referred to Out-Patient Department — ^treatment 

and prevention. 

4. Referred to Agencies — ^treatment and prevention. 

5. Sent to convalescent home, orphanage, etc., treat- 

ment and prevention. 

VII. Bibliography. 

Note — It is expected that modifications will be made to meet 
the needs of any particular study as in obstetrics, communicable 
diseases, etc. When the temperature chart is of particular inter- 
est, as in typhoid or pneumonia, a copy of the chart should be 
included in the study. 



PRINCIPLES AND PRACTICE OF NURSING 119 

The items given in the outline under the Social History and 
under Health Habits are not meant to suggest that the students 
gain this information by asking the patients questions, just get- 
ting so many facts. On the contrary this is discouraged. The 
items are suggestive and act as a guide as to what information 
would be helpful in understanding the needs of the patients. 
They are meant to stimulate and direct keen observation and 
to teach the students to interpret what their observations reveal 
with a view toward better, more intelligent and sympathetic 
nursing. It is understood that if a student makes a desirable ap- 
proach or contact with a patient, and the patient has any source 
of trouble or worry, he will be only too glad to talk to the nurse 
about it if she has won his confidence. 

Method of Using Case Studies. — Students are rotated from 
service to service in order that they may have a wide and varied 
experience in observing and caring for patients, and a broad 
knowledge of health and disease in all its aspects and manifesta- 
tions. It is, therefore, advisable that they keep case studies in 
each of the services in both hospital and dispensary. 

The student should select the study she wishes to make and 
submit it to the headnurse who will discuss with her the wisdom 
of her choice, and find out whether or not the student needs help 
and guidance before going on with it. The student should 
present a definite purpose for the study and a general plan. 

The number of studies to be made is an important item. There 
may be one every two weeks, or one each four or six weeks, etc. 
But, in general, it may be said that it is much better to have the 
students make one complete study in any service, one which 
really allows time for observation, for thought and study, than 
to have them make a number of hurried superficial reports which 
are not studies but exercises. The chief purpose of the study is 
to develop interest in the needs of the individual, the power of 
observation, thoughtful analysis, and an understanding of the 
patient which will insure adequate care. 

Conferences. — The studies should be handed to the headnurse 
promptly on the day assigned. She, together with the super- 



120 METHODS AND PRINCIPLES OF TEACHING 

visor, will correct and return them to the students in conference. 
It need scarcely be said that this individual instruction, while 
time consuming, is the most effective form of teaching, and 
creates not only a better understanding and care of patients, but 
a better understanding and a more co-operative, constructive 
relationship between headnurse, supervisor, and students. Group 
conferences as well as individual conferences should be held in 
which selected cases are discussed. 

Case Study References. — Such case studies form the most 
valuable and fruitful material for teaching and discussion. They 
recall our past experience in all its human relationships in the 
most vivid and realistic way, and form a valuable source of 
information which can be obtained in no other way. 

Case Study Committee. — To preserve this valuable informa- 
tion, as well as to improve the content and method of the studies 
themselves, it is suggested that a committee of headnurses, 
supervisors, and instructors be formed to study just what con- 
stitutes a good case study, and to select the best of the studies 
prepared by the students to build up in each school a case study 
reference library. At the end of the year, the best studies repre- 
senting the various services might be printed in an inexpensive 
loose-leaf pamphlet form which might be purchased and used as 
a text book. The students, by this stamp of approval, would be 
rewarded for their efforts and every student would be eager to 
have one, at least, of her studies selected. The law of effect in 
learning teaches us that satisfaction greatly promotes the 
learning process. 

Students Experience Records 
We have compared our course in nursing to a course in any 
other science, emphasizing the need for careful planning, teach- 
ing, and supervision of the laboratory experience. In a science 
laboratory, an instructor also requires the students to keep de- 
tailed records of their experiments under appropriate headings, 
such as the purpose of the experiment, the conditions under 
which it is conducted, the equipment used, the steps in the proc- 



PRINCIPLES AND PRACTICE OF NURSING 121 

ess, the results and conclusions. The need for similar records of 
our students' experience, to be corrected, graded, and discussed 
with the students, has already been emphasized. 

To carry out the analogy and to show the purpose and rela- 
tionship of the case studies and experience records, let us take, 
as an illustration of an experiment in a laboratory and its ap- 
plication to nursing, the examination of tissues or of blood cells 
with a microscope. (The same purpose and relationships might 
be shown by the study of the stars, in their constellations, their 
relative size and brightness, with the telescope.) 

As you know, it is advisable, for many reasons, to examine 
your field first with the low power. We see spread out before 
us a large field in which there are many, many cells. We see 
that there are two main kinds of cells, red and white, and again 
that there are different types of white cells. We gain some idea 
of the relative size and number of these cells in the various groups 
and their relations to each other, and if we perform certain tests 
we can actually estimate the total number in the blood and many 
other facts about them. 

Now the study of the student's practical experience recorded 
on these experience records, which we will examine later, seems 
to me analogous to this — it is, so to speak, examining our field 
of experience with the low power of the microscope. We see, 
and the student sees, her whole experience spread out before us in 
proper perspective. We see the number and variety of patients 
or cases cared for, the number in each group, all the treatments 
given in their proper relation, and all the symptoms observed in 
their proper relation to the disease or treatment. The records 
tell us what we have no other way of finding out. To go back 
to the use of the microscope! 

When a student looks through a microscope we have no way 
of knowing what she sees, understands, or learns — she may not 
be looking at the right field at all ; she may have the lens f ocussed 
badly ; she may be looking at a bubble of air or dust on the slide 
or lens. What she sees may mean little or nothing to her. To 
help Her, we must look through the microscope, help her to focus 



122 METHODS AND PRINCIPLES OF TEACHING 

it, direct her observations, have her draw, describe, compare 
with reference book, and record what she sees. 

It is the same with the practical experience. When a student 
is caring for patients, carrying out procedures, charting, etc., we 
have no assurance that she is learning anything beyond the mere 
mechanical adjustments required by the procedure unrelated to 
the individual patient or anything else. Many illustrations might 
be given of this failure to observe or to relate cause and effect. 
Just to give one illustration! 

The other day a student assisting with dressings had no obser- 
vations recorded on her experience record. When questioned, she 
said: "Oh! I am on the dressing carriage. I have no patients 
assigned." 

Now, as we all know, when that student was assigned to the 
dressing carriage it was to give her, not only the practice in 
aseptic technique, but the opportunity to observe dressings, the 
treatment and healing of wounds in relation to the diagnosis or 
operation and to the patient's general condition. 

Many similar illustrations might be given bearing out the 
truth of the saying that ''Many have eyes to see but see not, ears 
to hear and hear not." Two students, side by side, may observe 
the same operation, or treatment, or patient. Apparently both 
are seeing the same things and having the same experience; 
whereas the attention and thoughts of one may be focussed on 
some unimportant, irrelevant aspect of the situation, or even on 
something entirely remote. Even when greatly interested stu- 
dents frequently do not know (therefore must be taught) what 
to observe, what is important and what is unimportant. 

These records thus show us how meagre a student's observa- 
tions and education may be if we do not have some way of 
checking up as a means to helping and guiding her in focussing 
attention on what she is supposed to see and learn. They make 
it possible for not only one person but the whole faculty, and not 
only the faculty of the school but any expert group, to look 
through the microscope, as it were, at any student's experi- 
ence, if desired. This means that the minds of many people, 



PRINCIPLES AND PRACTICE OF NURSING 123 

instead of one, can reflect on this experience, evaluate it, and 
reshape it. 

In relation to the recording of practical experience Dr. Dewey 
gives us the following food for thought: ''Man differs from the 
lower animals because he preserves his past experiences." ''What 
happened in the past is lived again in memory." "And all this 
which makes the difference between bestiality and humanity, be- 
tween culture and merely physical nature, is because man 
remembers, preserving and recording his experiences." 

"At the time, however, attention is taken up with the prac- 
tical details and with the strain of uncertainty. Only later do 
the details compose into a story and fuse into a whole of mean- 
ing. At the time of practical experience man exists from moment 
to moment, preoccupied with the task of the moment." 

These records help the students to help themselves. They not 
only record the task of the moment but insure that the student 
will learn the diagnosis, the family or social problems, and that 
she will observe the symptoms of the disease, the result of 
treatments, as well as the factors in her work which make for 
success or failure. 

So much for the recording of the student's experience and the 
experience records. They should not only be of incalculable 
value to the students, but to us as a means of regulating their 
experience and developing a system of credits based on the 
actual content, teaching, and educational value of their experi- 
ence. 

Now let us go back to our study of the blood cells or tissues, 
this time with the high power lens. We see a greatly restricted 
field in which, perhaps, only one type of blood cell is represented. 
We are enabled, however, to make an intensive study of this 
one type, noting all its characteristics in detail. The knowledge 
gained is most illuminating and valuable, but any conclusions we 
might draw about blood cells and any applications we might 
make would be very misleading if we did not enlarge our field, 
compare these cells with others of the same type and of different 
types, and with the "low power" picture in the background. 



124 METHODS AND PRINCIPLES OF TEACHING 

This ''high power" examination is analogous to our case study 
— an intensive study of one selected patient, the emphasis being 
on the patient as a whole, the observation of symptoms, the social 
and medical aspects, and a constructive program of nursing care. 

Placing patients in a long row of beds, the beds all alike, the 
patients bathed, dressed alike, fed more or less alike, all subject 
to the same conditions, tends to rob them of their individuality 
and reduce all, more or less, to the same level just as the uniform 
does in an army. The case study is an effective way of restoring 
to the patient his individuality and of insuring that we meet 
his needs as an individual, a member of a family and of 
the community. 

The record below is a simple form on which the students can 
record each month an analysis and classification of their experi- 
ence in an organized way. It will be observed that emphasis 
is placed on the observation of the patient as a whole, on the 
number and variety of patients cared for during the month in 
terms of diagnosis and days cared for, upon tlie importance of 
observations and their interpretation, upon discrimination and 
thought in putting facts and observations together in their right 
relationships, and upon responsibility on the part of the student 
for self-analysis and progress in terms of standards of work 
given. 

Written Instructions. — To insure motivation and an intelli- 
gent interest and appreciation of statistics on the part of the 
students, the purpose of the records, their relation to the course, 
and to the case studies should be explained. To insure accuracy 
and uniformity, also, written instructions should be given. In 
addition, to avoid time spent in writing a mass of detail which 
detracts from the interest and usefulness of the records (because 
it obscures the real experience in nursing, in medicine, surgery, 
pediatrics, etc.), the supervisor in each service should write out 
what she considers "routine"; that is, what a student is expected 
to do for each patient assigned regardless in most cases of the 
diagnoses. For instance, the following might be the routine 
in a medical or surgical ward. The routine consists of the fun- 



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PRINCIPLES AND PRACTICE OF NURSING 129 

damentals in personal hygiene, and in normal living, and, there- 
fore, in preventive medicine and in nursing. 

Routine Nursing Cake in Medacal and 
Surgical Wards 

I. Morning Conference with Headnurse. 

Listen to the reading of the night report. Note particularly 
all information relating to the condition of each of your 
patients, such as the amount and character of sleep, 
symptoms and signs indicating change in condition, spe- 
cial treatments given, and all new medical and nursing 
orders. 

IL Personal Care of Patients. 

1. Greet patient, note general condition, and attend to 
immediate needs, with special attention to needs of the 
very ill. Plan work. 

2. Take temperature, pulse, and respiration of patients 
assigned. Chart in temperature book at once, and on 
charts during breakfast or before doctors' rounds. 

3. Prepare patients and serve breakfast. Feed helpless 
patients, leaving to last. 

4. During breakfast hour prepare for morning duties — 
collect linen and equipment, etc. 

5. Remove breakfast trays, etc. 

6. Give morning toilet, including use of bedpan and all 
necessary devices for making patients comfortable. Each 
patient must have at least three complete baths weekly, 
and all very ill patients must have a daily bath. Morn- 
ing care includes complete remaking of bed with due 
regard to economy in changing linen. Unless contra- 
indicated by doctor, all binders should be removed and 
replaced by clean binders when necessary. 

III. Patients' Belongings and Environment. 

1. Bedside tables: Attention to cleanhness, order, removal 
of unnecessary and undesirable articles including food, 
paper bags, etc., and providing proper toilet equipment 
in bedside tables. 

2. Attention to supply of fresh drinking water and other 
wants — occupational therapy, care of flowers, etc. 



130 METHODS AND PRINCIPLES OF TEACHING 

IV. Reporting, Charting, or Recording. 

1. Report to the headnurse any mental symptoms which 
may be interfering with patient's comfort (such as worry 
over family problems), and any symptoms which may 
suggest approaching delirium or any other psychoses. 

2. Report any physical symptoms or signs indicating change 
in patient's condition. Report any sign of pediculi or 
suspicion of bedsores. 

3. Chart temperature, pulse, and respiration, and all obser- 
vation of symptoms, etc., on the symptom record. Chart 
fluids taken on fluid or intake sheet. Chart intake, out- 
put, and defecation. All charting to be done before 
doctors^ "rounds" and at the earliest moment available. 

The student would record this in toto at the beginning of 
the month. Such items would not then appear again but only 
such treatments, medical, surgical, pediatric, etc., given by the 
student which had a definite relation to the treatment of the 
disease as shown in the record below. The names of the patients 
assigned would appear each day, but information relating to 
each already recorded would not be repeated but merely checked, 
and only new observations and treatments, etc., would be re- 
corded day by day. 

In the column w^hich calls for a criticism of their work, suc- 
cess or failure in measuring up to standards would be indicated 
opposite the treatment, stating the particular item of success 
or failure, such as ''unnecessary time taken because of lack of 
planning," "patient more comfortable because thin mattress was 
exchanged for a better one," "patient tired (loss of energy) 
because allowed to remain up too long," "patient made happy 
because news obtained about children," "patient looking uncom- 
fortable and work unfinished because pillows not properly 
arranged," and so on. 

The purpose of this analysis and criticism, as explained to the 
students, is to develop a constructively critical attitude toward 
their work and a personal responsibility for the advancement, 
not only of their own knowledge and skill, and capacity for 
independent work and self-direction, but of the general content 



PRINCIPLES AND PRACTICE OF NURSING 131 

and methods of nursing education. Without such an analysis 
we stumble on blindly in an unintelligent and inefficient manner. 
Through it we are unlikely to fail to measure up to the ideals, 
standards of work, and the successful service which we aim to 
achieve. 

In addition to the ideals, attitudes, and standards of work 
given, the form called the Headnurse Instructor's Report 
(frequently called the Efficiency Report) is explained to the 
students. (These reports when actually made are discussed 
with the students by the headnurse before placing them on 
file as a permanent record.) These standards all serve as meas- 
uring rods by which we may judge our own success and progress, 
and by which we may be judged. 

The analysis may fall under four main headings, such as: 
1. Method of planning and success in accomplishing the day's 
work as a whole. 2. The same in carrying out each duty or 
procedm-e, that is, did I carry out each procedure with due 
regard to the safety and comfort of the patient, the thera- 
peutic effect, etc.? 3. Interest and effort on the part of the stu- 
dent in finding out all the necessary information concerning 
patients for whom she is responsible. 4. Personal responsibility 
accepted by the student in availing herself of all the opportuni- 
ties for learning through experience. Criticisms made by others 
would be entered with quotations and name in brackets. 

The time required for keeping such records, according to 
statements made by the students, is from ten to twenty minutes 
daily. As an indication of the teaching and learning value of 
such records, a remark made by one of the students on the 
matter of time is enlightening. She said it would not take 
more than ten minutes each day if she "did not have to look 
up the meaning of so many words." Without such records 
would she have looked up the meaning of "words" and how much 
would she have learned by her experience? 

It may be emphasized here that if nursing is ever to make 
even a remote claim to being a science, or even to being con- 
ducted on a scientific basis, it must be built up like all branches 



132 METHODS AND PRINCIPLES OF TEACHING 

of science; that is, by the most careful, unbiased observations 
and recording of often seemingly trivial details from which — 
by organizing, classifying, analyzing, selecting, inferring, draw- 
ing, and testing conclusions — a body of knowledge or principles 
are finally evolved. 

Monthly Summary of Experience. — On this form the stu- 
dents record a summary of their daily experience indicated by 
the headings. The standards of work are checked if the daily 
job analysis column shows that due regard was given to each 
in carrying out the various treatments recorded. 

Evaluation of Experience. — The reverse side of the form 
shows the evaluation by the headnurse of the experience or con- 
tent of the course in terms of number and variety of patients, 
treatments, etc., and whether or not the student's hours on duty 
and her interest and effort made it possible to make the most 
of it. This evaluation is important in creating in both teacher 
and students the proper conception of the ward experience, and 
supplies necessary data for measuring the actual experience of 
the students. 

Conferences. — The daily experience sheets should be handed 
promptly to the headnurse at stated intervals to determine 
whether or not the student is profiting by her experience, and 
for correction and further guidance, and then returned to the 
student in conference. 

The monthly summary should also be discussed with the 
students, then filed as a permanent record for future use in 
evaluating and reshaping the experience of that student (and 
future students), avoiding useless repetitions, and making up 
deficiencies in the various services. 

Method of Keeping Records. — A satisfactory way of keep- 
ing all records kept by the students is to have a study table or 
desk in the ward and a file with a folder for each student in 
which she keeps her work. It is then accessible to both student 
and teacher. Its presence in the ward also emphasizes the edu- 
cational aspect of the experience. 

Method of Grading Experience. — The student's achievement 



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PRINCIPLES AND PRACTICE OF NURSING 135 

and progress in any experience should be evaluated by the head- 
nurse in conference with the teaching supervisor. Fifty per cent, 
or perhaps more, might be allowed for the knowledge, under- 
standing, and skill shown in the actual care of patients, fifty 
per cent for the knowledge, understanding, and appreciation 
shown in written work in the form of case studies, experience 
records, plans for nursing care of patients, charts, and individual 
treatment cards, etc. Such a method gives a fairer estimate 
of the student's experience. It gives credit to the student who 
stands high in both knowledge and skill, and to the student 
who is "good in theory but not in practice," and vice versa. It 
gives the student a better understanding of what constitutes 
experience and learning by experience. 

In grading, recognition should be given to the student's 
achievement in the light of her previous experience and educa- 
tion, her individual capacity, her health and general fitness for 
the particular service. 

Value of the Written Word. — Historians, philosophers, and 
educators all tell us "that some form of written language is an 
indispensable basis for all civilization or progress, and that when 
written records were lost, or became meaningless because no one 
could read or write, then the civilizations which they alone 
made possible quickly disintegrated," because the written word 
is what made the quick dissemination of knowledge, feelings, 
and united action, necessary for a civilization, possible. 

The written word, necessary for a civilization, is likewise 
necessary for the progress of the nursing profession. Writing, 
or recording our thoughts, our feelings, our ideas of people and 
things, our aims, our plans, the results of our own work or 
studies and those of others has many values. Writing crystal- 
lizes, clarifies our ideas, and makes for conciseness and accuracy; 
things "look different," in writing, and we will often say things 
we would hesitate to commit ourselves to in writing. Facts 
not written, also, reach only a few people and have little pro- 
ductive or permanent value. Written facts can be tested and 
verified; they may be classified and analyzed; comparisons may 



136 METHODS AND PRINCIPLES OF TEACHING 

be made and new relationships and principles revealed. Records 
serve as a future reference and guide and by systematic review 
and checking up, they enable us to evaluate the soundness of 
our methods and the progress made in both content or knowl- 
edge and in methods of work. 

All of this makes for a better quality and standard of work, 
better service to our patients, better teaching, more scientific 
methods, better education for our students, better nurses, and bet- 
ter service to the community in the prevention and cure of dis- 
ease ; and all these sum up the aims of the course in the Principles 
and Practice of Nursing and of the Profession of Nursing. 

REFERENCES 

pEWEY, John. — Democracy and Education. Experience and 
Nature, Human Nature and Conduct.